Biliary disease Flashcards
What would happen if you didnt have a gallbladder
Release of digestive enzymes would not be timed as nicely, but eventually you can return to eating fatty foods
What is bile
Fluid secreted from liver (500ml/d) and stored in gallbladder
Made up of water, electrolytes, bile salts, phospholipids,
What is cholelithiasis
Stones in the gallbladder AKA gallstones
What is cholecystitis
Inflammation of the gallbladder
What is choledocolithiasis
Stones in the CBD
What is cholangitis
Inflammation of the bile ducts
What is Cholestasis
disruption of bile flow, regardless of cause
RF for cholelithiasis are
Female Fluffy (obese) Forty (age >40) Fertile (pregnancy) Rapid weight loss Estrogens, BCP Ethnicity (native american, hispanic, caucasian)
What are the types of gallstones
Cholesterol stones (MC) Pigment stones (calcium, bilirubin, proteins)
How can cholelithiasis present
ASx (MC)
Sx (biliary colic, or with complications)
What are complications of Cholelithiasis
Acute cholecystitis
Acute choledocolithiasis
Ascending cholangitis
Acute pancreatitis
How do you diagnose cholelithiasis
*US (initially)- can show gallstones, wall thickening, pericholecystic fluid
CT Abdomen- more expensive, more radiation, less Sn, but will show majority of stones
Abd XR has limited value in Dx gallstones
How do you manage asymptomatic cholelithiasis
If incidental finding and ASx, you should NOT do a CCY
How do you manage Symptomatic cholelithiasis
Cholecystectomy (CCY)
What is biliary colic
Temporary obstruction of cystic duct
MCC by gallstones which cause pressure in gallbladder to rise= pain
As gallbladder relaxes, obstruction is relieved
NO INFLAMMATION!!*****
How does biliary colic present
Dull, constant RUQ pain w/ possible radiation to R shoulder blade
MC after a fatty meal
Associated nausea, vomiting, and diaphoresis
Sx are TEMPORARY**, 4-6 hours max
What if they have biliary colic pain but it lasts >6 hours
This is acute cholangitis! Treat it more urgently
On PE for biliary colic you may find
They are NOT acutely ill
Vital signs are normal (no fever or tachy)
NO jaundice
NO scleral icterus
+/- RUQ ttp, but NO rebound, NEG murphy’s sign
What labs should you get to eval biliary colic
CBC
LFT
Amylase and lipase
(will all be normal)
How do you diagnose biliary colic
*US- expect to see gallstones or sludge, which is causing the temp obstruction
How do you manage biliary colic
Prophylactic CCY to prevent recurrent Sx and complications
MUST have r/o alternate diagnoses bc your workup is frequently normal. Gall stones could be present, but they may not be the root of the Sx
What is biliary dyskinesia
Functional gallbladder disorder;
No sludge, no stones, no inflammation. Gallbladder just doesn’t function correctly!
Consider biliary dyskinesia in a patient who
has NO gall stones or sludge on US
Has normal labs (CBC, LFT, Am, Lip)
How can you diagnose biliary dyskinesia
HIDA scan with CCK!
Inject HIDA, which should normally be excreted in bile and taken up by gallbladder w/in 30 min. Then measure radioactivity in gallbladder
Give CCK to stimulate gallbladder to contract and measure EF, but NOT if the pt has stones!
Abnormal gallbladder motility is EF <35-40%
How do you manage biliary dyskinesia
CCY if biliary dyskinesia and:
Biliary Sx
HIDA w/ CCK EF <35-40% that reproduces Sx
R/o PUD, gastritis, GERD cardiac ischemia
What is acute cholecystitis
Acute inflammation of the gallbladder due to sustained obstruction of cystic duct
MCC is cholesterol stones
What history findings point you to acute cholecystitis
Steady, severe RUQ pain +/- right shoulder radiation
Occurs s/p fatty meal
Associated nausea, vomiting, diaphoresis, fever
Sx persist >4-6 hours!
History of biliary colic
On PE for acute cholecystitis you may find
Ill appearing fever, tachycardia NO jaundice NO scleral icterus RUQ ttp w/ palpablt, tender gallbladder \+/- rebound and guarding *Positive murphy's sign
What are complications of acute cholecystitis
Gangrene, esp. if old, immunosuppressed, or delayed treatment Perforation Generalized peritonitis Cholecystoenteric fistula Gallstone ileus
What labs should you get for acute cholecystitis
CBC: elevated WBC w/ left shift**
LFT: normal, mils ALT/AST, alk phos, and bili elevation
UA: elevated urobilinogen
Pancreatic enzymes: mild elevation of amylase
If alk phos and bilirubin are significantly elevated when you suspect Acute cholecystitis, you must
rule out Cholangitis!
*Alk phos and Bilirubin= obstruction!
How do you diagnose acute cholecystitis
*US- may see gallstones, thick wall, pericholecystic fluid, + sonographic murphy’s sign
HIDA scan: confirm Dx if the US was not definitive- will show failure of GB to fill
How do you manage acute cholecystitis
Admit
Analgesics (ketorolac, morphine, meperidine)
NPO
IVF, electrolytes
IV abx (cipro, flagyl
*Early CCY if healthy, low risk (ASA class I-II)- do it when they are not acutely inflammed
What is criteria for emergent CCY
IF severe complication (gangrene, perforation, peritonitis)
Clinical deterioration despite supportive therpay
What is the ASA classification system
I: normal, healthy pt II: mild systemic dz III: severe systemic dz IV: severe systemic dz that is life threatening V: will not survive w/o surgery VI: brain dead, organ donor surgery
How do you manage high risk acute cholecystitis patients
Supportive therapy
Consult specialist for risk vs benefir of CCY
If therapy fails, consider cholecystostomy tube to decompress
What is chronic cholecystitis
Chronic inflammation of the gallbladder associated with mechanical irritation (gallstones) or repeat acute cholecystitis
Usually diagnosed s/p CCY when looking at histology
What is acalculous cholecystitis
Similar to acute cholecystitis but no gallstones, and may have jaundice
Common in critically ill patients (associated stasis and ischemia)
Worse than calculous cholecystitis
How do you diagnose acalculous cholecystitis
US
LFT
CBC
PROMPT Tx of acalculous cholecystitis includes
CCY vs. Cholecystostomy (CCY best)
Why do you want to be prompt about treating acalculous cholecystitis
bc secondary infection of the gallbladder is common;
Check blood cultures, start broad spectrum Abx, and prevent gallbladder gangrene!
What is choledocolithiasis
Stone in the CBD that blocks bile flow and caused jaundice*
History findings that indicate choledocolithiasis are
RUQ or epigastric pain N/v Sx similar to PUD Jaundice*, pruritis, tea colored urine, light colored stool (look for Hx of biliary colic)
PE for UNcomplicated choledocolithiasis (no cholangitis) shows
mild discomfort afebrile, no tachy, no hypotension Jaundice* Scleral icterus* \+/- RUQ ttp, no peritoneal signs
What findings would make you suspect cholangitis with choledocolithiasis
Fever
Jaundice
Leukocytosis
Prominent RUQ ttp
What labs should you get for uncomplicated choledocolithiasis
CBC (no leukocytosis)
LFT (if w/ cholestasis, high CONjugated bili and high Alk Phos)
Pancreatic enzymes (normal)
What imaging can you get for choledocolithiasis
RUQ US (first test)- may see CBD stone, dilated CBD, or stones in the GB If uncertain, can get an MRCP
What does MRCP show
Biliary and pancreatic ducts
Confirms diagnosis of CBD stone
How do you manage choledocolithiasis
Remove stone to prevent cholangitis or pancreatitis
+/- prophylactic Abx (cipro, flagyl)
ERCP as therapeutic test to remove stone, insert stent, and perform sphincterotomy
Then CCY
When is it ok to perform an ERCP in choledocolithiasis
When you know you will have to treat
Because of how invasive it is, do not do it just for diagnostic purpose
What is ascending cholangitis
Infection of the biliary tract, MC in CBD- like a pond of water just sitting
Associated with biliary obstruction
Bacteria infects bile (ascending infection from duodenum)
AKA: Pus under Pressure! so, this is an emergency!
What history findings point you to ascending cholangitis
RUQ epigastric pain
jaundice
fever
Hx of biliary colic or disease
On ascending cholangitis PE you may find
acutely ill appearing, diaphoretic fever, tachycardia, hypotension jaundice scleral icterus RUQ ttp, guarding AMS
Acute presentation of ascending cholangitis is
**Charcot’s triad: Fever, RUQ pain, jaundice
**Reynolds pentad: Fever, RUQ pain, Jaundice, hypotension, mental status changes
Signs of peritonitis and sepsis
What are some lab findings in acute cholangitis
Leukocytosis (>20K) LFT: elevated Conjugated bili and alk phos** indicate cholestasis Pancreatic enzymes: nl-mild high UA: high urobilinogen Blood cultures may show sepsis
How do you diagnose ascending cholangitis
US
MRCP (CBD stone and dilation)
How do you manage ascending cholangitis
Admit Consult GI NPO, IVF Broad spectrum Cipro+Flagyl MUST relieve obstruction ERCP w/ sphincterotomy and stone extraction Follow with CCY
How does an ERCP treat ascending cholangitis
Sphincterectome
Stone extraction from CBD
Relieve obstruction
+/- stent
If you suspect biliary disease, what diagnostics do you order to r/o others
CBC w/ diff: r/o infection
Amylase/lipase: r/o pancreatitis (mild bump with acute biliary dz)
LFT: high alk phos and conjugated bili= cholestasis 2/2 obstruction. ALT/AST with transient elevations
US
MRCP: helpful w/ dx stones/obstruction in CBD when US non-diagnostic
Additional diagnostics in biliary disease are
HIDA scan to confirm cystic duct obstruction. Add CCK to measure EF for biliary dyskinesia
ERCP: relieve CBD obstruction
What is primary biliary cirrhosis
Autoimmune destruction of small intrahepatic bile ducts causing cholestasis
Leads to cirrhosis and liver failure
MC in females 35-60
How does primary biliary cirrhosis present
*Fatigue, pruritis before jaundice (2/2 bile getting into circulation)
Arthritis, RUQ pain, CREST Sx
If a patient comes in with itching, what labs do you get
Conjugated bili
Alk Phos
ALT, AST
(pruritis is usually skin, but need to r/o bile in the circulation!)
What labs should you get to eval primary biliary cirrhosis
LFT (high alk phos, then high Con bili; high GGT) *Anti-mitochondrial antibody (AMA) ANA IgM HLD
What is GGT
a very sensitive liver marker of inflammation
If alk phos is high and you don’t know whether it is from liver or bone, GGT helps tell you its liver!
How do you diagnose primary biliary cirrhosis
Liver biopsy!
Confirm dx and stage dz
How do you manage primary biliary cirrhosis
Urso (med to help w/ stasis)
DEXA to monitor bone density
What is primary sclerosing cholangitis
Inflammation/fibrosis of medium and large intra/extra hepatic ducts
Progress to cirrhosis (survival is 10-12 yrs s/p dx)
MC in men
Sx of primary sclerosing cholangitis are
*Fatigue, pruritis after jaundice, steatorrhea
Complications of primary sclerosing cholangitis are
Biliary stricture Cholangitis Cholangiocarcinoma Gallbladder cancer Colon cancer
How do you diagnose primary sclerosing cholangitis
LFT have cholestatic pattern (high alk phos and conj bili)
*P-ANCA, ASMA, ANA, IgM
ERCP: Dx and therapeutic
MRCP: will see multifocal stricturing w/ intra/extra hepatic ductal dilation
Liver biopsy is usually non-diagnostic
How do you manage primary sclerosing cholangitis
Monitor bone density
Manage biliary strictures with ERCP (dilate/stent)
Monitor for complications
Liver transplant with advanced disease
What is Gilbert’s syndrome
Deficiency in enzyme to conjugate bilirubin in the liver
Leads to *Unconjugated hyperbilirubinemia withOUT hemolysis
They are totally ASx
Labs for Gilbert’s syndrome show
High unconjugated bili
Normal CBC, blood smear, reticulocytes, all other LFT are normal
RF for gallbladder cancer are
Cholelithiasis
Gallbladder polyps >1cm
Salmonella infection
How does gallbladder cancer present
ASx or looks just like cholelithiasis
Sx can suggest malignancy (anorexia, wt loss)
What is Cholangiocarcinoma
Adenocarcinoma of bile ducts, associated with PSC and choledochal cysts
How does cholangiocarcinoma present
*Jaundice upper abd pain anorexia weight loss pruritis
Cholangiocarcinoma labs show
Cholestasis: high conj bili and alk phos
Elevated CA-19-9 (pancreatic cancer marker)
What is ampullary cancer
Cancer of ampulla of vater, where CBD and pancreatic duct meet
Associated w/ familial adenomatous polyposis and HNPCC
How does ampullary cancer present
*Obstructive jaundice
occult GIB w/ microcytic anemia
abdominal pain
