Biliary Disease

Question 1

What is cholelithiasis?

Answer 1

Gallstones in the bladder

Question 2

What causes pain w/ cholelithiasis?

Answer 2

Contraction of the GB against the stones, transient cystic duct blockage

Question 3

Most common risk factors for gallstones?

Answer 3

Female, Fat, Forty, Fertile.

Question 4

Racial predisposition for gallstones?

Answer 4

Native Americans

Question 5

Med/medical/surgical therapies that predisposes for gallstones?

Answer 5

OCP use, TPN, small bowel resection

Question 6

Medical history that predisposes for gallstones?

Answer 6

+ family history, rapid weight loss, chronic hemolysis (pigmented stones)

Question 7

Chief complaint w/ gallstones?

Answer 7

• Postprandial abdominal pain (usually in the RUQ) that radiates to the right subscapular area or the epigastrium.

Question 8

Pattern of pain, associated sxs w/ gallstones?

Answer 8

Pain is abrupt, followed by gradual relief, and often associated with nausea and vomiting, fatty food intolerance, dyspepsia, and flatulence. RUQ tenderness, +/- palpable GB.

Question 9

Diagnosis of gallstones?

Answer 9

XR - bad test (only 10-15% radioopaque).
RUQ U/S is 85-90% sensitive.
Upper GI series r/o hiatal hernia or ulcer.

Question 10

Treatment of gallstones?

Answer 10

• Elective cholecystectomy
• pre-op ERCP for CBD stones
• Nonsurg candidates: dietary modification

Question 11

What is acute cholecystitis?

Answer 11

Prolonged blockage of the cystic duct, usually by an impacted stone → ob- structive distention, inflammation, superinfection, and possibly gangrene of the gallbladder (acute gangrenous cholecystitis)

Question 12

Who is at risk for acalculous cholecystitis?

Answer 12

Acalculous cholecystitis oc- curs in the absence of cholelithiasis in chronically debilitated patients, those on TPN, and trauma or burn victims.

Question 13

Presentation of acute cholecystitis?

Answer 13

RUQ pain, nausea, low-grade fever, and vomiting. More severe/longer than biliary colic.

Question 14

Physical exam signs of acute cholecystitis?

Answer 14

RUQ tenderness, inspiratory arrest during deep palpation of the RUQ (Murphy’s sign), low-grade fever, leukocytosis, mild icterus, and possibly guarding or rebound tenderness may be present on examination.

Question 15

What labs to order when suspect acute cholecystitis?

Answer 15

CBC, amylase, lipase, and an LFT panel should be obtained.

Question 16

Ultrasound findings of acute cholecystitis?

Answer 16

Ultrasound may demonstrate stones, bile sludge, pericholecystic fluid, a thickened gallbladder wall, gas in the gallbladder, + ultrasonic murphy’s sign

Question 17

What other imaging is diagnostic of acute cholecystitis?

Answer 17

HIDA scan. Nonvisualization of GB = acute cholecystitis.

Question 18

Treatment of acute cholecystitis?

Answer 18

Hospitalize patients, administer IV antibiotics and IV fluids, and replete electrolytes.
Perform early cholecystectomy (within 72 hours of symptom onset) along with either a preoperative ERCP or an intraoperative cholangiogram to rule out common bile duct stones.

Question 19

Patients with significant medical problems and acute cholecystitis?

Answer 19

Since 50% of cases resolve spontaneously, hemodynamically stable pa- tients with significant medical problems (e.g., DM) can initially be man- aged medically with a four- to six-week delay in surgical treatment.

Question 20

Complications of acute cholecystitis?

Answer 20

Gangrene, empyema, perforation, gallstone ileus, fistulization, sepsis, abscess formation

Question 21

What is choledocholithiasis?

Answer 21

Gallstones in the common bile duct.

Question 22

Presentation of choledocholithiasis

Answer 22

Although sometimes asymptomatic, it often presents with biliary pain, jaundice, episodic colic, fever, and pancreatitis.

Question 23

Lab findings associated with choledocholithiasis?

Answer 23

↑ alkaline phosphatase and total bilirubin

Question 24

Treatment of choledocholithiasis?

Answer 24

Management generally consists of ERCP with sphincterotomy fol- lowed by semielective cholecystectomy.

Question 25

What is Acute Cholangitis?

Answer 25

An acute bacterial infection of the biliary tree that commonly occurs 2° to ob- struction, usually from gallstones (choledocholithiasis) or 1° sclerosing cholangitis (progressive inflammation of the biliary tree associated with ulcer- ative colitis).

Question 26

What organisms are associated with acute cholangitis?

Answer 26

Gram-􏰃 enterics (e.g., E. coli, Enterobacter, Pseudomonas) are common.

Question 27

Risk factors for acute cholangitis?

Answer 27

bile duct stricture, ampullary carcinoma, and pancreatic pseudocyst.

Question 28

Names for classic presentation of acute cholangitis?

Answer 28

Charcot’s triad and Reynaud’s pentad

Question 29

What is charcot’s triad?

Answer 29

RUQ pain, jaundice, fever/chills

Question 30

What is Reynaud’s pentad?

Answer 30

Charcot’s triad + hypotension and AMS.

Question 31

Lab values of acute cholangitis?

Answer 31

Look for leukocytosis, ↑ bilirubin, and ↑ alkaline phosphatase.

Question 32

What diagnostic modalities are used for acute cholangitis?

Answer 32

Clinical.
Ultrasound vs. CT.
ERCP both dx and tx (biliary drainage).

Question 33

Treatment of acute cholangitis?

Answer 33

ICU admission, IVF, BP support, IV abx broad spectrum. Emergency bile duct decompression via

• ERCP
• Percutaneous transhepatic drainage
• or open decompression