Biliary Disease

Question 1

Cholelithiasis occurs as ***

Answer 1

Cholelithiasis (gallstones) occurs as a result of supersaturation of bile with cholesterol (70%), pigments such as bilirubin (20%), or both (10%) combined with delayed emptying of the gallbladder (stasis).

Question 2

Choledocholithiasis definition

Answer 2

Choledocholithiasis refers to the presence of gallstones within the common bile duct.

Question 3

Definition of acute cholecystitis and acalculus

Answer 3

Acute Cholecystitis is inflammation of the gallbladder and is related to the presence of gallstones in 90-95% of cases. Acalculous cholecystitis occurs in <10% of cases and is seen more often in patients who are elderly, post-operative, or critically ill from other causes.

Question 4

Cholangitis definition

Answer 4

Cholangitis is inflammation of the bile ducts and is most often caused by a polymicrobial bacterial infection. Biliary obstruction – such as from a stone or neoplasm – serves as a major factor in its pathogenesis. The condition is less common than cholecystitis, but has significantly higher mortality (40% vs 15%).

Question 5

Biliary colic definition

Answer 5

Classic presentation of biliary colic (episodic pain due to gallstone obstruction of the neck of the gallbladder) is right upper quadrant (RUQ) or epigastric pain associated with nausea and vomiting. The pain may radiate to the back, right flank or tip of the right scapula. Described as an intermittent or “colicky” pain that is burning, pressure-like, or heavy in nature. The patient may relate a history of prior similar episodes that occur in relation to the ingestion of fatty meals. Most episodes of uncomplicated biliary colic are self-limited and resolve within 4-6 hours with or without treatment.

Question 6

Charcot’s triad

Answer 6

Charcot’s triad (RUQ pain, fever, and jaundice) is the classic presentation of cholangitis and is seen in 70% of patients.

Question 7

Physical exam findings

Answer 7

• Biliary colic may only reveal RUQ or epigastric tenderness.
• Jaundice may be present when there is obstruction of the biliary tree as in cholangitis and choledocholithiasis

Question 8

Murphy’s sign

Answer 8

he cessation of deep inspiration on palpation over the gallbladder is considered a positive Murphy’s sign which has good sensitivity (63-90%), but low specificity (45-65%) for acute cholecystitis

Question 9

Lab work

Answer 9

• Large elevations in bilirubin and alkaline phosphatase should – bile duct obstruction and the need for further evaluation

Question 10

Cholelithiasis Lab findings

Answer 10

WBC normal
AST/ALT normal or slightly elevated
Bilirubin (conjugated) Normal
Alkaline phosphatase normal or slightly elevated Amylase/Lipase Normal

Question 11

Choledocholithiasis Lab findings

Answer 11

WBC normal
AST/ALT normal or slightly elevated
Bilirubin (conjugated) Elevated
Alkaline phosphatase Elevated
Amylase/Lipase Normal

Question 12

Acute Cholecystitis Lab findings

Answer 12

WBC Normal, Elevated or decreased if septic
AST/ALT normal or slightly elevated
Bilirubin (conjugated) normal or slightly elevated
Alkaline phosphatase normal or slightly elevated
Amylase/Lipase Normal

Question 13

Cholangitis Lab findings

Answer 13

WBC Normal, Elevated or decreased if septic
AST/ALT Elevated
Bilirubin (conjugated) Elevated
Alkaline phosphatase Elevated
Amylase/Lipase Normal or slightly elevated

Question 14

Cholelithiasis Imaging

Answer 14

• US is quite sensitive (>95%) for the identification of cholelithiasis which is diagnosed by the presence of mobile echogenic material within the gallbladder (GB) that casts posterior shadows.
• Dilation of the common bile duct (> 6mm in adults, > 8mm in elderly) indicates the likely presence of biliary duct stone or other obstruction and may be seen in choledocholithiasis and cholangitis.
• important ultrasonographic findings of acute cholecystitis include the presence of gallstones, GB wall thickening (5mm or greater), pericholecystic fluid, and/or a positive sonographic Murphy’s sign (maximum tenderness with pressure from the US transducer directly over the gallbladder). Distention of the GB and increased blood flow to GB on Doppler studies can also be seen.

Question 15

HIDA Scan

Answer 15

• HIDA scan is 90-94% sensitive for the presence of acute cholecystitis and is indicated if US is equivocal or negative for cholecystitis in the presence of a high clinical suspicion.
• Lack of visualization of the GB within 4 hours after the injection constitutes a positive study and indicates the presence of cholecystitis or cystic duct obstruction

Question 16

CT Imaging

Answer 16

• In the setting of equivocal ultrasound results, CT can be considered as the next diagnostic step if HIDA scan is unavailable or if a broad differential to the patient’s abdominal pain is still being considered.
• acute cholecystitis due to its ability to detect GB distention, GB wall thickening, and pericholecystic fluid. It is furthermore highly sensitive (>96%) for evidence of biliary obstruction.

Question 17

ERCP

Answer 17

When choledocholithiasis is suspected an ERCP may be indicated. ERCP is used to both diagnose and treat diseases of the biliary and pancreatic ducts
- risks including pancreatitis (~5%), perforation of the GI tract or ductal system, dye reactions, and bleeding

Question 18

Risk factors for Gall bladder disease

Answer 18

Female gender
Age > 40 years
Family history
Obesity
Multiparity
Rapid weight loss
Sickle Cell or other hemolytic disorders (pigmented stones)
Diabetes (increased risk of cholecystitis)

Question 19

Treatment of biliary colic

Answer 19

Cholecystectomy

Otherwise, pain control and antiemetics if needed.

Question 20

Treatment of choledocholithiasis

Answer 20

ERCP or surgery

Question 21

Treatment of cholecystitis and cholangitis

Answer 21

• Symptom control
• Antibiotics (ampicillin/sulbactam, a fluoroquinolone, or a third-generation cephalosporin +/- metronidazole should be administered early.)
• Cholecystectomy