Biliary Diseases Flashcards
Cholelithiasis
- Gallstones are usually asymptomatic in most patients and often found incidentally on imaging studies for other issues
- more common in women
Classic cholelithiasis pain presentation is
RUQ with radiation to the R shoulder and infra scapular area
subscapular pain
Gallstones are classified according to
chemical composition
Treatment for cholelithiasis
-NSAIDs
-Laparoscopic cholecystectomy for symptomatic disease
(Only done in asymptomatic if porcelain gallbladder, stones >3cm, or if a patient is a candidate for bariatric surgery or cardiac transplant)
What to give people who can’t have cholecystectomy surgery
Ursodeoxycholic acid:
-A bile salt given orally for up to 2 years which can help dissolve some cholesterol stones in patients who are unable to have or refuse to have surgery
- Gallstones usually reoccur by 5 years after medication is stopped
- Excess bile salts eliminates itching
How to screen before procedure or to see stones in asymptomatic pts
ultrasound
Clinical example: weight loss procedure, lost weight, right upper shoulder pain, think __________
cholecystitis issue
Porcelain Gallbladder
Chronic cholecystitis can cause hardening of the gallbladder
on XRAY seen as ring enhancing area
Case: A 45yo woman presents to the ER with a c/o steady RUQ tenderness and epigastric pain that began 30min after eating a burrito bowl at chipotle
She felt nauseated and vomited once on the way to the hospital. She has a low grade temp to 100F
She just saw in the news that there has been an e.coli outbreak and she is worried about food poisoning
- “Stabbing pain” in RUQ and upper back
- E. coli doesn’t make you sick right away- usually more than 24 hours to see s/s
- Has happened before after meals- fatty meals make it worse (think hamburger)
Acute Cholecystitis is associated with
gallstones 90% of the time
- Often precipitated by a fatty meal
- Vomiting may give temporary relief
- Physiologically – a stone becomes impacted in the cystic duct and inflammation develops around the obstruction
When acute cholecystitis is not caused by stones, could be caused by
CMV, cryptosporidiosis or microsporidiosis in advanced HIV patients; or by vasculitis
During Acute Cholecystitis, labs will show
WBCs often elevated, LFTs and bilirubin can be elevated, serum amylase may also be mildly elevated
Physical exam sign you should see
- Murphy’s sign is positive when you palpate the RUQ and ask the patient to breathe deeply
- POSITIVE if patient develops pain that radiates to the R infrascapular area or if patient’s inspiration stops short
- Sonographic Murphy’s sign is positive when a patient reports maximum discomfort when the ultrasound probe is over the gallbladder
How to diagnose acute cholecystitis
-Ultrasound may show gallstones, biliary sludge, biliary ductal dilation, gallbladder wall thickening, pericholecystic fluid, and/or a positive sonographic Murphy’s sign
If ultrasound is not convincing of diagnosis, next step is
next step would be to do a hepatic iminodiacetic acid scan (HIDA)
- Test most reliable when bilirubin is under 5mg/dL
- HIDA scan is positive when the gallbladder does NOT light up and when the common bile duct DOES light up
Possible complication of acute cholecystitis
Gangrene of the gallbladder:
- Symptoms of acute cholecystitis severe and lasting 24-48h
- Due to ischemia from splanchnic vasoconstriction
- Could lead to perforation, abscess
- Obese, elderly, diabetics at higher risk
Another complication of acute cholecystitis is Acalculous cholecystitis, consider this if pt has
fever and RUQ pain 2-4 weeks after major surgery or in critically ill ICU patients- sitting, laying on backs, sludge in gallbladder
What can be done if patient too unstable for cholecystectomy?
Drain the gallbladder, go to interventional radiology and they put a drain in (drain stays in for a while)
Cholecystitis is very dangerous in elderly because
Can be life threatening- dangerous in elderly because they main not feel the pain (may only present with malaise)
Chronic Cholecystitis results from
from repeated episodes of acute cholecystitis or from chronic irritation of the gallbladder due to stones
-Occasionally chronic inflammation creates polypoid changes inside the gallbladder giving the gallbladder a strawberry appearance (mucous filled)
Hydrops of the gallbladder can occur if
the cholecystitis subsides but the cystic duct obstruction persists generating a gallbladder filled with mucoid fluid
Acute cholecystitis can often improve with
gut rest, pain medications, and antibiotics
Antibiotics used for acute cholecystitis
- A cephalosporin + metronidazole (gram – coverage and anaerobe coverage, for all bacteria in gut)
- Fluoroquinolone + metronidazole
- Piperacillin/tazobactam
- Carbapenem (imipenem, meropenem, ertapenem)
-Given high risk for recurrence, interval cholecystectomy can be planned when symptoms improve
Case: A 38yo man presents to your office with a c/o yellow tinge to the whites of his eyes over the past 2 weeks. Patient does report some episodic nausea and vomiting which can be accompanied by epigastric pain.
- Has had more diarrhea recently, stool is greasy, worse with fatty food
- Yellow-green stool
- Urine color is darker than normal
- Itchy skin all over
- Ask about travel, see if they may have a liver fluke
Think Choledocholithiasis and Cholangitis
Choledocholithiasis and Cholangitis descrition
- Often a h/o epigastric pain accompanied by jaundice
- Sometimes patients present with painless jaundice as their chief complaint
- Cholangitis suspected if there are signs of sepsis
- Etiology is a stone in the bile duct which requires an ERCP for diagnosis and possible intervention
Charcot’s Triad
TEST AND BOARDS
- Frequently occurring attacks of RUQ abdominal pain
- Jaundice associated with RUQ pain
- Chills and fever
Reynold’s Pentad
TEST AND BOARDS
The classic findings of Charcot’s triad for acute cholangitis PLUS:
- Altered mental status
- Hypotension
-Indicates probable supperative cholangitis and is an endoscopic emergency (when patient becomes septic or much sicker, they progress to reynold’s pentad)
CT and lab findings during Choledocholithiasis and Cholangitis
-Labs can demonstrated striking increases in LFTs and hyperbilirubinemia
-Serum amylase may be elevated indicating a secondary pancreatitis
-CT may show dilated bile ducts
-ERCP provides the most accurate determination of the extent of the obstruction especially when bile duct diameter is >6mm, when ductal stones are seen on ultrasound, or when bilirubin is >4mg/dL
Sphincterotomy with stone extraction or stenting can be done as needed during this procedure- open sphincter and remove stone
What test provides the most accurate determination of the extent of the obstruction?
- ERCP, especially when bile duct diameter is >6mm, when ductal stones are seen on ultrasound, or when bilirubin is >4mg/dL
- Sphincterotomy with stone extraction or stenting can be done as needed during this procedure- open sphincter and remove stone
Treatment of Choledocholithiasis and Cholangitis
- Bile duct stones should be removed even in asymptomatic patients
- If a patient has concurrent cholecystitis, cholecystectomy is generally performed during the same hospital stay
- If no signs of cholecystitis, cholecystectomy can be done electively in 2 weeks
Antibiotics for Choledocholithiasis and Cholangitis
-Targeted towards gram negative pathogens are often administered acutely via IV, and patients are sent home on ~2 weeks of p.o. agents
Ciprofloxacin/metronidazole, cefuroxime/metronidazole, amoxicillin/clavulanate
Case: A 47yo woman is seen 3 weeks after a liver transplant for a h/o Hep C with cirrhosis. She is feeling well post-op but reports some itching skin and feels there may be some yellowing to the whites of her eyes. She has had low-grade temps for the past week and some vague nausea. No changes in stools
Think biliary stricture
Biliary stricture
- Benign biliary strictures are generally due to injury around a surgical anastomosis ~95% of the time
- 5% of cases can be due to direct injury to the abdomen, pancreatitis, or prior endoscopic sphincterotomy
- Jaundice can develop rapidly if complete occlusion occurs
Most common complication of a stricture
Cholangitis
-Biloma or infected fluid collection/abscess could also arise
Clinical clues that should make you think biliary structure
- Surgical- problem is tiny ducts, keeping them open, etc- think biliary stricture
- Huge injuries of abdomen (kids going over bike handlebars, hitting in stomach, damage to pancreas causing biliary stricture)
Biloma
Backflow of a ton of bile that has built up (see around liver)
MRCP is valuable _______
in demonstrating strictures
Magnetic resonance cholangiopancreatography
ERCP permits _______
(Endoscopic retrograde cholangiopancreatography) permits biopsy to evaluate for possible malignancy, sphincterotomy to allow closure of a bile leak, and dilation/stent placement (more interventional)
Risk of post-ERCP pancreatitis in challenging cases
Case: A 35yo man with a history of ulcerative colitis and poor compliance with management presents to the ER with his sister who saw him for the first time in a year and was very concerned about his appearance.
Patient with yellow discoloration to his skin and to the sclera of his eyes.
Diffuse pruritus, no blood in stool, stools are yellow-green, dark urine (spilling bilirubin)
Think Primary Sclerosing Cholangitis
MORE CLUES: Patient reports he hasn’t been eating well and had noticed the yellowing slowly over the past 2 months. Patient also has fatigue and loose stools. Labs reveal high direct and indirect bilirubin, elevated LFTs. MRCP is performed.
With Primary Sclerosing Cholangitis MRCP will show
Common bile duct has punctuated stricture (string of pearls appearance)
Primary Sclerosing Cholangitis is most often associated with
ulcerative colitis
KNOW FOR EXAM
Facts about Primary Sclerosing Cholangitis
- Most common in men aged 20-50 years
- PT HAS HISTORY OF ULCERATIVE COLITIS! (exam)
- Progressive jaundice over time, pruritus, labs consistent with cholestasis
- Diagnosis on MRCP with classic cholangiographic findings (string of pearls)
- 10-20% risk of cholangiocarcinoma
Treatment for Acute bacterial cholangitis component
Treated with antibiotics targeted towards gram negative pathogens (ciprofloxacin, 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems)
Full treatment for Primary Sclerosing Cholangitis
- Ursodeoxycholic acid can improve LFTs and decrease itching
- Possible balloon intervention of some of the sclerosed areas
- Possible stenting as a short term solution to relieve symptoms (long-term stenting may increase complications)
- Liver transplantation for those with cirrhosis and clinical decompensation
Prognosis for Primary Sclerosing Cholangitis
- Average survival 9-17 years and up to 21 years in some studies
- Survival may be less with a dominant bile duct stricture
- Higher risk for colon cancer associated with longer survival
- Survival rates with liver transplantation are as high as 85% at 3 years
