Biliary System Flashcards
What percentage of patients with asymptomatic gallstones develop symptoms over 5 years?
10%
What are 3 reasons to perform a cholecystectomy on a patient with asymptomatic gallstones?
- Immunocompromised patients
- Porcelain gallbladder
- Stones >3cm
Differential diagnosis for pain in the RUQ.
- Cholelithiasis
- Biliary Colic
- Acute cholecystitis
- Gastroenteritis
- Peptic ulcer disease
- Acute hepatitis
- Renal colic
- Pleural based pneumonia
- Pyelonephritis
- GERD
- IBS
- Inferior wall MI
What are common factors predisposing to gallstones?
Family history, female, obese, increasing age, obesity, recent pregnancy, previous diagnosis of gallstones
Define Murphy’s sign.
Inspiratory arrest during deep palpation of the RUQ due to pain.
What is the imaging study of choice for gallbladder disease?
Ultrasound
What blood work should be ordered in the workup of suspected gallbladder disease?
CBC with differential, amylase, lipase, and liver function panel
What is the treatment of choice for symptomatic cholelithiasis?
Cholecystectomy
What antibiotics, if any, are required for symptomatic cholelithiasis?
A single preoperative dose of a 1st generation cephalosporin.
What are the major complications of a cholecystectomy?
- Injury to the common bile duct; can cause chronic biliary stricture, infection, and possibly cirrhosis.
- Injury to the hepatic artery; can cause hepatic ischemic injury or bile duct ischemia and stricture.
What percent of the population have gallstones by 60, and what is the M:F?
12% and 25%, 1:2 M:F
What populations are at highest risk for gallstones?
Chile, Sweden, and Pima Indians
What percent of patients with asymptomatic gallstone disease develop symptoms within 1 year?
1-2%
What percentage of gallstones are radiolucent?
85%
What are the two types of pigmented gallstones?
Black gallstones, and brown gallstones
What are black gallstones composed of?
calcium bilirubinate, calcium phosphate, and calcium carbonate
What are the risk factors for developing black pigmented gallstones?
hemolytic disorders, cirrhosis, and ileal resection
What are brown pigmented gallstones composed of?
bacterial cell bodies, calcium bilirubinate, and calcium palmitate
What are risk factors for developing brown pigmented gallstones?
Biliary stasis and infection (especially Klebsiella spp)
Describe the pathogenesis of acute calculous cholecystitis.
Obstruction of the cystic duct by an impacted gallstone that presists causes inflammation of the gallbladder. Inflammation leads to pain which, unlike biliary colic, is unremitting.
What are the severe complications of acute calculous cholecystitis?
Empyema, gangrene, contained or free gallbladder perforation, and abscess formation.
What is Mirizzi syndrome?
A rare complication of calculous cholecystitis where a gallstone becomes impacted in the neck of the gallbladder or cystic duct and compresses the common bile duct or common hepatic duct, resulting in obstruction and jaundice.
What is the sensitivity and specificity of ultrasound in diagnosing cholelithiasis?
84% and 99%, respectively
What is the sensitivity and specificity of ultrasound in diagnosing acute cholecystitis?
88% and 80%, respectively
What features can be seen on US in patients with cholecystitis?
Gallbladder wall thickening, pericholecystic fuild, and a sonographic Murphy sign.
What are the findings on HIDA scan of acute cholecystitis?
Non filling of the gallbladder after 4 hours.
What is the initial management for patients with acute cholecystitis?
Hospitalization, IVF resuscitation, and IV Abx.
What antibiotics, if any, should be given to patients with acute cholecystitis?
Piperacillin/Tazobactam
Describe the surgical management of acute cholecystitis?
For mild disease, early lap chole is recommended. For moderate disease, early or delayed LC may be performed. For severe disease, or in patients with severe concomitant illness, percutaneous cholecystostomy can be performed with subsequent cholecystectomy 4-6 weeks later.
What is the advantage of early vs delayed lap chole in patients with acute cholecystitis?
Significantly fewer readmissions for interval complications, and significantly reduced hospital length of stay.
