Biliary Tract Disease Flashcards
What demographics have a high rate of cholesterol gallstones?
Mexican Americans and several American Indian tribes, particularly the Pima Indians in the Southwest
What are the risk factors for biliary tract disease?
Women affected 3x more than men Prevalence increases with age Clusters in families Obesity Multi-parity High-dose estrogen OCPs Rapid weight loss Prolonged TPN Pregnancy is thought to predispose one to gallstones
Between meals, sphincter of Oddi contracts and diverts bile into:
Gallbladder
What stimulates contraction of the gallbladder and relaxation of the sphincter of Oddi in response to fats in duodenum?
Cholecystokinin (CCK)
What is bile composed of?
cholesterol, bile salts, and phospholipids
What is the most common type of gallstone?
Mixed stone
What is a mixed stone?
High proportion of cholesterol with bile acids and lecethin
What are the types of gallstones?
Mixed Cholesterol Black Brown (Sludge)
What are black stones indicative of?
Hemolytic disease and cirrhosis
What are brown stones and where are they usually found?
Infected bile
Usually present in the CBD
Where do most Choledocholethiasis come from?
Gallbladder
What are primary common bile duct stones?
Formed in the CBD itself
What are primary CBD stones usually from?
Stasis or infection
Which imaging is the standard of care for gallstones?
Ultrasound
What is the recommended treatment for asymptomatic gallstones for both diabetics and non-diabetics?
Observation
Cirrhosis leads to an increased incidence of what?
Gallstones
What is the recommended treatment for a patient with asymptomatic gallstones in a pt with cirrhosis?
Careful observation
Early intervention for Child’s A & B when symptoms develop
What is the recommended treatment for a pt with hemolytic anemia and asymptomatic gallstones?
Cholecystectomy at time of splenectomy
What is the recommended treatment for a pt with Somatostatinoma and asymptomatic gallstones?
Cholecystectomy recommended at time of tumor resection
What is the recommended treatment for a pt undergoing bariatric surgury and asymptomatic gallstones?
Likely to develop symptoms in post op period
Adding cholecystectomy to procedure adds minimal M & M
What is the recommended treatment for a pt with porcelain gallbladder and asymptomatic gallstones?
Cholecystectomy
Porcelain gallbladder associated with 20-60% cancer risk
What is biliary colic caused by?
a stone that lodges in the cystic duct causing an obstruction
Why do symptoms resolve with biliary colic?
The stone does not stay lodged and when it becomes un-lodged, the symptoms resolve
What cause pain in biliary colic?
distention of the gallbladder, not inflammation
Where is the pain located with biliary colic?
RUQ, less likely epigastric. May go to back. May radiate to right shoulder
What are the characteristics of pain with biliary colic?
Visceral - dull, aching
Severe
Increases in severity, plateaus for several hours, then decreases
What symptoms are associated with biliary colic?
N/V
What is the duration of pain with biliary colic?
1 – 4 hours
What are precipitating factors of biliary colic?
Large fatty meals
What are alleviating factors of biliary colic?
None
What will the abdominal exam show with biliary colic?
Soft, ND +/- tenderness
What will be on labs with biliary colic?
CBC w/diff – nl
LFTs - nl
What will the ultrasound show with biliary colic?
gallstones w/o GB wall thickening or pericholocystic fluid and nl CBD
What is the recommended treatment for biliary colic?
Elective cholecystectomy
Less complications, shorter hospital stay if operation done electively rather than at time of acute cholecystitis
When should gallbladder dyskinesia be suspected?
In pts with sx suggestive of biliary colic but no stones
What imaging is used for gallbladder dyskinesia?
Nuclear cholescintigraphy (HIDA, PPIDA, radionuclide biliary scan) with CCK stimulation
What is a normal gallbladder ejection fraction?
Normal > 35%
What causes acute cholecystitis?
Persistent stone impaction in the cystic duct causes the gallbladder to become distended and progressively inflamed
How does acute cholecystitis present?
pain of biliary colic that persists and worsens
What have most acute cholecystitis patients experienced in the past?
Biliary colic
Where is the pain located with acute cholecystitis?
RUQ or epigastric. May go to back. May radiate to right shoulder
What are the characteristics of pain with acute cholecystitis?
Sharp and better localized. Constant and severe
What are the associated sx of acute cholecystitis?
N/V, fever, chills
What is the duration of pain in acute cholecystitis?
3 – 4 hours to several days
What are the precipitating factors of acute cholecystitis?
Large fatty meals
What are the alleviating factors of acute cholecystitis?
None
What vital signs are associated with acute cholecystitis?
+/- fever, +/- tachycardia, +/- hypotension
What will the abdominal exam show with acute cholecystitis?
Soft, tender in RUQ
May have localized guarding or rebound
+ Murphey’s sign
Mass RUQ in 20% - tender!
What will labs show for acute cholecystitis?
CBC w/diff - +/- leukocytosis with left shift
LFTs – Most likely normal. You can have mild elevation of AST (< 1.5)
What will US show for acute cholecystitis?
US - gallstones w/ distended GB GB wall thickening pericholocystic fluid US Murphy’s sign Nl CBD
What is the tx for acute cholecystitis?
NPO IVF IV ABX IV pain meds Anti-emetics Early cholecystectomy (within a few days of symptom onset)
What bacteria is seen with acute cholecystitis?
E. coli, K. pneumonia, S. faecalis
Gram – aerobes and enterococcus
What is the ddx with acute cholecystitis?
Acute hepatitis
Acute pancreatitis
Perforated peptic ulcer
Acute appendicitis
Acalculous cholecystitis is seen in what demographic?
Usually in a patient who is acutely ill for other reasons
Common in ICU patients
What will US show for acalculus cholecystitis?
no stones but other findings of acute cholecystitis
What imaging besides US should be ordered for acalculus cholecystitis?
Nuclear cholescintigraphy (HIDA, PPIDA, radionuclide biliary scan)
What is the tx for acalculuous cholecystitis?
Cholecystectomy or cholecystectomy tube
What is an empyema?
Bacterial proliferation in the obstructed GB
What signs and sx are seen with an empyema?
Marked fever and leukocytosis
What is the tx for an empyema?
Early decompression
What are the sx of gallbladder perforation?
High fever, chills, rigors, septic shock
What causes an Emphysematous cholecystitis?
Gas-forming organism
What does an Emphysematous cholecystitis have a higher risk of?
Gangrene
What condition predisposes a pt to have Emphysematous cholecystitis?
DM
What is the treatment for Emphysematous cholecystitis?
Emergency cholecystectomy after stabilization
What is Hydrops (mucocele) of the gallbladder?
Over-distended gallbladder with mucoid or clear and watery content
From gallstone disease
Non-inflammatory
From gallstone disease
How does Hydrops (mucocele) of the gallbladder present?
Presents similar to biliary colic but sx last longer and palpable minimally tender GB - sometimes to pelvis
What is the gold standard cholecystectomy surgery?
Laperoscopic cholecystectomy
What are the risks of laperoscopic cholecystectomy?
Adhesions poor visualization of critical structures hemorrhage bile duct injury injury to another organ
What is the positioning of the patient and surgeons for Laperoscopic cholecystectomy?
pt supine with arms out
Surgeon on the left, assistant on the right
What are intraoperative cholangiograms used for?
Identify CBD stones and delineate biliary anatomy
Occult CBD stones exist in 4-10% of pts
What is the triangle of Calot?
Usual location of the cystic artery
What structures form the triangle of Calot?
Common hepatic duct, cystic duct, edge of liver
What are the complications of a lap chole?
CBD injury – rare, serious complication Bowel injury Bleeding Infection Bile leak
What is the duct of Luschka?
tiny ducts that drain from the liver into the body of the GB, can cause bile leak
What are the two structures that could leak bile?
Duct of Luschka
Cystic duct stump
How is a bile leak evaluated?
Labs and PIPIDA scan +/- other imaging to look for fluid collection
How is a bile leak treated?
Percutaneous drainage or ERCP stent placement or combination or surgical drain placement
What is the post-cholecystectomy syndrome?
Epigastric or RUQ pain after cholecystectomy
40% of patients have minor GI complaints
Gas, bloating, abdominal pain, or diarrhea
What is most often the cause of persistent post-cholecystectomy syndrome?
Wrong preoperative dx
What causes choledocholethiasis?
Common bile duct stones
Where do most stones originate in choledocholethiasis?
GB and migrate to CBD
What physical sign is consistent with choledocholethiasis?
Intermittent jaundice
What can choledocholethiasis progress to?
Cholangitis (inflammation of bile ducts)
What other signs/sx are associated with the jaundice caused by choledocholethiasis?
Puritis, clay colored stools, tea colored urine
What is the location of pain with choledocholethiasis?
RUQ. Could be intermittent. Could have no pain at all
What will vitals show for a pt with choledocholethiasis?
Normal
What will the abdominal exam show for a pt with choledocholethiasis?
Soft NTND. May be tender
What will labs show for choledocholethiasis?
CBC w/diff – usually normal
LFTs - elevated T. bili, mostly direct, marked elevation of alk phos and GGT. Mild elevation of AST and ALT.
Amylase and lipase - normal
What will US show for choledocholethiasis?
US - gallstones +/- CBD stone. Dilated intra- and extra- hepatic ducts. Dilated CBD >6-8mm.
What test other than US should be ordered for choledocholethiasis?
Cholangiography (MRCP or ERCP or IOC)
What are the advantages/disadvantages of MRCP?
less invasive. Can’t be therapeutic
What are the advantages/disadvantages of ERCP?
Invasive, but can be therapeutic
What is the ultimate treatment for CBD stones?
Lap chole prevents future CBD stones
How are cbd stones treated if they pass on their own?
Wait to pass then do lap chole
How are CBD stones treated if they will not pass?
ERCP with sphinterotomy and stone extraction
What is an alternative to ERCP for finding a CBD stone?
Surgical CBD exploration laparoscopically
What is acute ascending cholangitis?
Septic process of the biliary tree
Combination of inflammation from bacteria in the bile and some degree of biliary obstruction
What is the most common cause of acute ascending cholangitis?
CBD stones or benign strictures
What are some other causes of acute ascending cholangitis?
malignancy internal biliary stents pancreatitis Mirizzi’s syndrome viral infection parasitic infection duodenal ulcer
What is the ddx for acute ascending cholangitis?
Acute hepatitis
Acute pancreatitis
Perforated peptic ulcer
Acute appendicitis
Where is the location of pain for acute ascending cholangitis?
RUQ or epigastric. May go to back. May radiate to right shoulder
What are the characteristics of the pain for acute ascending cholangitis?
Visceral - dull, aching. Steady and severe
What are the associated sx with acute ascending cholangitis?
N/V/F/C, yellowing of the eyes and skin, clay colored stools and tea colored urine
What will general survey show for acute ascending cholangitis?
Uncomfortable, juandice, may have confusion, may be diaphoretic and appear very ill (septic)
What will vitals show for acute ascending cholangitis?
Fever, tachycardia, hypotension if suppurative
What will the abdominal exam show for acute ascending cholangitis?
RUQ tenderness, may have localized guarding and rebound
What will labs show for acute ascending cholangitis?
CBC w/diff - leukocytosis with left shift
LFTs - elevated T. bili, mostly direct, marked elevation of alk phos and GGT. Mild elevation of AST and ALT
Amylase and lipase - normal
What will US show for acute ascending cholangitis?
US - gallstones +/- CBD stone. Dilated intra- and extra- hepatic ducts. Dilated CBD >6-8mm
What is Charcot’s Triad for acute ascending cholangitis?
Fever
Jaundice
RUQ pain
Occurs in only 20% of pts
What is Reynold’s Pentad for acute SUPPURATIVE cholangitis?
Charcot’s triad +
Mental status changes (Delirium)
Hypotension (Shock)
What is the tx for acute ascending cholangitis?
NPO IVFs Broad-spectrum antibiotics Biliary decompression Drainage can be endoscopic – ERCP (GI) or percutaneous transhepatic - PTC (radiologist)
What is the tx for acute ascending cholangitis if the cause is due to stones?
Lap chole
What is a gallstone ileus?
When a large gallstone (2 cm) causes a SBO by lodging in the distal ileus
How does a gallstone get into the small bowel?
Erodes through the gallbladder directly into the small intestine creating a fistula
The stone passes along the small bowel and creates an obstruction usually at the distal ileum
What demographic usually gets a gallstone ileus?
Elderly
What is the imaging of choice for a gallstone ileus and what will it show?
Plain films of the abdomen – SBO with intrahepatic biliary air and a calcification in the RLQ
What is the treatment for a gallstone ileus?
NGT
IVF
Enterotomy with stone extraction +/- cholecystectomy and fistula repair
What demographic is at highest risk for galbladder cancer?
American Indians and Hispanics
women>men
What are the risk factors for gallbladder cancer?
cholesterol gallstones single large gallstone calcified GB (porcelain) biliary Salmonella typhi infection biliary polyps > 1 cm
What are the sx of early gallbladder cancer?
asymptomatic or that of biliary colic
What are the sx of advanced GB cancer?
Vague RUQ pain, weight loss and malaise
Jaundice in 50%
Hard mass in RUQ – may be non-tender
What is the only cure for GB cancer?
complete surgical removal
Cholecystectomy alone if only at peritoneal surface (rare)
En bloc resection of the gallbladder, liver bed, and lymph nodes
Formal liver resection
What is the 5 year survival rate for GB cancer?
<5%
What is Cholangiocarcinoma?
Malignancy of the biliary duct system
Intrahepatic, extrahepatic (perihilar), and distal extrahepatic
In what demographic is Cholangiocarcinoma seen?
Equal among sexes
50 – 70 year old
How does cholangiocarcinoma progress?
Slow growing but advance locally and are usually non-resectable at diagnosis
What are the most common tumors seen in cholangiocarcinoma and where are they located?
Klatskin (perihilar) tumors
At the bifurcation of right and left hepatic ducts
What are the risk factors for cholangiocarcinoma?
UC
Sclerosing cholangitis
Choledochal cysts
Parasitic disease
What are the sx of cholangiocarcinoma?
Most common sx is jaundice (progressive) Pruritis Weight loss Abdominal pain Cholangitis
What will the physical show for cholangiocarcinoma?
Yellow
Hepatomegaly
May have Curvoisier’s sign
What is Curvoisier’s sign?
Enlarged palpable gallbladder in patient with jaundice. Dilation of GB with thin walls
What will show on labs for cholangiocarcinoma?
same as choledocholethiasis except bilirubin can get much higher
What imaging can be used to evaluate cholangiocarcinoma?
US, CT, MRI
PTC, ERCP, EUS – can biopsy
What is the treatment for cholangiocarcinoma?
Resection if cure is a possibility
Bypass or stent for symptom relief
What is the 5 year survival rate of cholangiocarcinoma with resection?
5-25%
