Biliary Tract Disorders Flashcards
What are the biliary Tract Disorders?
- Cholelithiasis
- Cholangitis
- Acute Cholecystitis
- Chronic Cholecystitis
- Gallbladder Cancer
What is cholelithiasis?
1 or more calculi (gallstones) in the gallbladder
What are the risk factors for cholelithiasis?
1. 4F’s A. Female gender B. Fat C. Forty D. Fertile: pre-menopausal women 2. Native American ethnicity 3. Western diet 4. (+) FH
What is the pathophys of cholelithiasis?
- Cholesterol stones account for 85% of gallstones
A. Form from bile that’s supersaturated (sludge) w/cholesterol produced by liver - Crystals or “microstones” are formed, then form into larger stones
- Stone may be “silent” or become lodged in cystic duct or CBD, causing pain & cholecystitis
- Stones can fill the entire gallbladder
What are the characteristics of black pigmented gall stones?
- Small & hard
A. Ca bilirubinate & inorganic Ca salts
B. Form w/alcoholic liver disease, chronic hemolysis, & older age
What are the characteristics of brown pigmented gall stones?
- Soft & greasy
A. Bilirubinate & fatty acids
B. Form during infection, inflammation, and parasitic infestation
What are the sxs of cholelithiasis?
- 80% asymptomatic
- +/- N/V
- Biliary colic
A. Most common
B. Not immediately after meal, but 1-2 hrs after fatty meal: Sudden onset RUQ pain w/radiation to back or right shoulder/arm, ↑ intensity w/in 15-60 min, steady intensity (not colicky) up to 12 h (usually < 6 h), then gradually disappears over 30-90 min, leaving dull ache
What are the dx studies for cholelithiasis?
- Ultrasonography
A. Method of choice for detecting gallstones
95% sensitivity & specificity - Cholescintigraphy (HIDA scan w/Ejection Fraction)
A. If needed
B. May not pick up biliary sludge
What is the prognosis for cholelithiasis?
- Once biliary symptoms begin, they’re likely to recur
- Pain returns in 20-40% of patients/year
- 1-2% of patients/yr develop complications
What complications can result from cholelithiasis?
- Cholecystitis
- Choledocholithiasis
- Cholangitis
- Gallstone pancreatitis
What is the treatment for cholelithiasis?
- Cholecystectomy for symptomatic stones
A. Laparoscopic or open laparotomy - Stone dissolution
A. Gallstones dissolved by oral bile acids over months
B. Ursodeoxycholic acid (Ursodiol) 8-10 mg/kg/day po
C. Dissolves 80% of tiny stones (< 0.5 cm) w/in 6 mo
What is included in Calot’s Triangle?
AKA: Hepatobiliary TriangleorHepatoCystic Triangle
- Cystic Duct
- Common Hepatic Duct
- Margin of Liver
What are the surgical landmarks for cholecystectomy?
- Calot’s Triangle
2. Mascagni (Lund’s) Lymph Node
What is Mascagni (Lund’s) Lymph Node?
- Sentinel lymph node of the gallbladder
2. ↑ in size incholecystitis& cholangitis
Who are candidates for stone dissolution?
- Pt who declines surgery
- High surgical risk
- Small, radiolucent stones (likely cholesterol)
What meds may be helpful for ppl with dumping syndrome?
- Bile Acid Sequestrants
A. Bind bile acid in intestine preventing reabsorption
B. Lower hepatic cholesterol
C. Used w/ statin or nicotinic acid
Synergistic effect
Cholestyramine (Questran/Light), colestipol (Colestid), colesevelam (Welchol)
What is acute cholecystitis?
- Inflammation of gallbladder 2° to gallstone obstructing cystic duct
- Develops over hours
What is the most common complication of cholelithiasis?
- Acute cholecystitis
2/ 95% of patients w/acute cholecystitis have cholelithiasis
What are the sxs of acute cholecystitis?
- Similar to biliary colic but lasts longer & more severe
- Vomiting is common
- Fever (low grade)
- Right subcostal tenderness
- (+) Murphy’s sign
A Guarding
How are the sxs of cholecystitis different in elderly?
- In elderly, sx’s may be systemic & nonspecific
A. Anorexia B. Vomiting C. Malaise D. Weakness E. +/- fever
When do sxs resolve in acute cholecystitis?
Sx’s begin to subside in 2-3 days & resolve w/in 1 wk in 85% of patients
What are the complications of acute cholecystitis?
1. 10% perforate A. Peritonitis 2. ↑ pain, high fever, rigors, & rebound tenderness or ileus suggest: A. Empyema (pus in the gallbladder) B. Gangrene C. Perforation 3. Mirizzi's syndrome A. Rare B. Gallstone impacted in cystic duct or Hartman's pouch, compresses & obstructs CBD → cholestasis (jaundice)
- Gallstone pancreatitis
A. Gallstones pass from gallbladder into CBD block pancreatic duct - Cholecystoenteric fistula
A. Rare
B. Large stone erodes thru gallbladder wall, creating a fistula into small bowel
When should you suspect CBD obstruction in acute cholecystitis?
- When sx’s accompanied by jaundice, CBD obstruction is likely
A. Due to stones or inflammation
What dx studies are used in acute cholecystitis?
- Labs
A. Leukocytosis w/ L shift
B. Bilirubin up to 4 mg/dL & mildly elevated alkaline phos - Ultrasonography
A. Best test to detect gallstones
B. Pericholecystic fluid or thickening of the GB wall → acute inflammation - Cholescintigraphy (HIDA scan)
A. If USN results are equivocal or (-) & ↑ suspicion
B. Failure of the radionuclide to fill GB → obstructed cystic duct
C. Low EF → GB dysfunction
What is the tx for acute cholecystitis?
- Hospital admission, IV fluids, & analgesia w/ketorolac (Toradal) or opioid
- NPO
- NG tube to suction if vomiting or ileus present
- IV antibiotics for possible infection
A. Empiric Tx [gram (-) enteric organisms]
IV ceftriaxone (Rocephin) 2 g q 24h
+
IV Metronidazole (Flagyl) 500 mg q 8h
OR
IV piperacillin/tazobactam (Zosyn) 4 g q 6h alone - Cholecystectomy
A. Early cholecystectomy preferred
B. In 1st 24-48 h IF:
-Dx clear & low surgical risk
-Elderly or diabetic & higher risk of infectious complications
-Empyema, gangrene, perforation, or acalculous cholecystitis
What is Cholangitis?
- CBD blocked & infection occurs backing up into the liver
A. Can block the hepatic or common bile ducts & force bile into the circulation → jaundice - MEDICAL EMERGENCY
What is charcot’s Triad?
RUQ pain
Fever
Jaundice
What is the pathophys of cholangitis?
- Choledocholithiasis
- Biliary tract manipulations/interventions & stents more common cause
- Hepatobiliary malignancies less common cause
What is the most common causative agent/pathogen for cholangitis?
Most common anaerobic organism- Bacteroides fragilis
What are the dx studies for cholangitis?
- Ultrasonography
- CBC w/diff
A. Leukocytosis w/L shift - LFT’s
A. Hyperbilirubinemia
B. ↑ alkaline phos - Blood cultures
What is the antbiotic rx for cholangitis?
1. IV antibiotic therapy A. IV ceftriaxone (Rocephin) 2 g q 24h Gm (-) \+ IV metronidazole (Flagyl) 500 mg q 8h anearobes \+ IV ampicillin 4 g q 6h Gm (+) OR IV Fluoroquinolone (Cipro or Levaquin)
What is the tx for severe or toxic cholangitis?
May require emergency biliary drainage
What is the non-abx tx for cholangitis?
- Diagnostic & therapeutic purposes (drainage)
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Percutaneous transhepatic cholangiography (PTC)
A. Needle inserted through skin at R subcostal area, guide-wire passed through liver & into the blockage in the bile duct
B. Stent placed - Eventual cholecystectomy if candidate
What is chronic cholecystitis?
- Long-standing gallbladder inflammation almost always due to gallstones
- Damage ranges from modest chronic inflammatory cells to a fibrotic, shrunken gallbladder
What is a porcelain gallbladder?
Extensive calcification due to fibrosis from chronic cholecystitis
What are the sxs of chronic cholecystitis?
- Gallstones intermittently obstruct cystic duct causing recurrent biliary colic
- Generally mild sx’s
- RUQ tenderness may be present, but no fever
- Fever suggests acute cholecystitis
- Once episodes begin, they are likely to recur
What are the dx studies for chronic cholecystitis?
- Ultrasonography
A. Suspected in patients w/recurrent biliary colic + gallstones
B. Shows gallstones and sometimes a shrunken, fibrotic gallbladder - HIDA scan w/ EF is no stones seen on US
What is the tx for chronic cholecystitis?
- Laparoscopic cholecystectomy
2. Low fat diet until surgery
What are the epidemiological characteristics for gallbladder cancer?
- ↑ risk in 6th-7th decades
- Female > Male (3:1)
95% associated w/ gallstones - 6x more common in Native Americans
- 22% increased risk if “porcelain GB” or calcified wall is seen on U/S
What type of gallblader cancer is most common?
> 90% are Adenocarcinoma
What are the sxs of gall bladder cancer?
- Similar to biliary colic but lasts longer & more severe
- Vomiting is common
- Fever (low grade)
- Right subcostal tenderness
- (+/-) Murphy’s sign
A. Guarding
What is the treatment for gallbladder cancer?
Chemo has less than a 40% response rate
What is the prognosis for gallbladder cancer?
- 5 years survival is 5%
2. Mean life expectancy 6-8 months
