Biliary Disease Flashcards
What is cholelithiasis?
Gallstones in the bladder
What causes pain w/ cholelithiasis?
Contraction of the GB against the stones, transient cystic duct blockage
Most common risk factors for gallstones?
Female, Fat, Forty, Fertile.
Racial predisposition for gallstones?
Native Americans
Med/medical/surgical therapies that predisposes for gallstones?
OCP use, TPN, small bowel resection
Medical history that predisposes for gallstones?
+ family history, rapid weight loss, chronic hemolysis (pigmented stones)
Chief complaint w/ gallstones?
- Postprandial abdominal pain (usually in the RUQ) that radiates to the right subscapular area or the epigastrium.
Pattern of pain, associated sxs w/ gallstones?
Pain is abrupt, followed by gradual relief, and often associated with nausea and vomiting, fatty food intolerance, dyspepsia, and flatulence. RUQ tenderness, +/- palpable GB.
Diagnosis of gallstones?
XR - bad test (only 10-15% radioopaque).
RUQ U/S is 85-90% sensitive.
Upper GI series r/o hiatal hernia or ulcer.
Treatment of gallstones?
- Elective cholecystectomy
- pre-op ERCP for CBD stones
- Nonsurg candidates: dietary modification
What is acute cholecystitis?
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)
Who is at risk for acalculous cholecystitis?
Acalculous cholecystitis oc- curs in the absence of cholelithiasis in chronically debilitated patients, those on TPN, and trauma or burn victims.
Presentation of acute cholecystitis?
RUQ pain, nausea, low-grade fever, and vomiting. More severe/longer than biliary colic.
Physical exam signs of acute cholecystitis?
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.
What labs to order when suspect acute cholecystitis?
CBC, amylase, lipase, and an LFT panel should be obtained.
Ultrasound findings of acute cholecystitis?
Ultrasound may demonstrate stones, bile sludge, pericholecystic fluid, a thickened gallbladder wall, gas in the gallbladder, + ultrasonic murphy’s sign
What other imaging is diagnostic of acute cholecystitis?
HIDA scan. Nonvisualization of GB = acute cholecystitis.
Treatment of acute cholecystitis?
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.
Patients with significant medical problems and acute cholecystitis?
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.
Complications of acute cholecystitis?
Gangrene, empyema, perforation, gallstone ileus, fistulization, sepsis, abscess formation
What is choledocholithiasis?
Gallstones in the common bile duct.
Presentation of choledocholithiasis
Although sometimes asymptomatic, it often presents with biliary pain, jaundice, episodic colic, fever, and pancreatitis.
Lab findings associated with choledocholithiasis?
↑ alkaline phosphatase and total bilirubin
Treatment of choledocholithiasis?
Management generally consists of ERCP with sphincterotomy fol- lowed by semielective cholecystectomy.
What is Acute Cholangitis?
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).
What organisms are associated with acute cholangitis?
Gram- enterics (e.g., E. coli, Enterobacter, Pseudomonas) are common.
Risk factors for acute cholangitis?
bile duct stricture, ampullary carcinoma, and pancreatic pseudocyst.
Names for classic presentation of acute cholangitis?
Charcot’s triad and Reynaud’s pentad
What is charcot’s triad?
RUQ pain, jaundice, fever/chills
What is Reynaud’s pentad?
Charcot’s triad + hypotension and AMS.
Lab values of acute cholangitis?
Look for leukocytosis, ↑ bilirubin, and ↑ alkaline phosphatase.
What diagnostic modalities are used for acute cholangitis?
Clinical.
Ultrasound vs. CT.
ERCP both dx and tx (biliary drainage).
Treatment of acute cholangitis?
ICU admission, IVF, BP support, IV abx broad spectrum. Emergency bile duct decompression via
- ERCP
- Percutaneous transhepatic drainage
- or open decompression
