Biliary tree Flashcards
What is Acute Cholangitis? Common bugs? Causes?
Acute cholangitis is a bacterial infection of the biliary tree, most commonly caused by obstruction, but also associated with instrumentation, neoplasm, or stricture. Many patients can present with overwhelming sepsis, and if the biliary tree is obstructed, decompression is needed emergently. It is one of the few GI emergencies requiring immediate intervention. The most common organisms causing infection of the biliary tree are enterobacteriaceae, and as such, treatment should generally consist of broad spectrum gram negative antibiotics with additional anaerobic coverage. This can be achieved by the combination of a 3rd generation cephalosporin with metronidazole or with piperacillin/tazobactam alone. The most common cause of cholangitis is choledocholithiasis, which is likely in this patient.
What is Charcot’s triad? Reynold’s pentad?
upper abdominal pain, fever and jaundice. The condition may progress rapidly to Reynold’s pentad, which consists of Charcot’s triad with confusion and hypotension
MRCP versus ERCP for Acute cholangitis?
A magnetic resonance cholangiopancreatography (MRCP) would not be a first line test in an unstable patient. It takes much too long to be practical. A MRCP can be ordered in patients who cannot undergo an ERCP and are otherwise stable or intermediate risk of obstruction; however, an MRCP is not a therapeutic intervention. If obstruction is visualized within the biliary tree on CT scan the patient will then have to be taken for an ERCP. In patients in whom urgent intervention is needed (such as this patient who is presenting with severe sepsis), an ERCP should performed on an emergent basis for biliary decompression if obstruction is seen.
What organisms do we need to worry about with Ascending Cholangitis?
Ascending cholangitis is an infection of bile ducts secondary to ductal obstruction. Patients present with leukocytosis and a cholestatic liver enzyme pattern. Empiric treatment of cholangitis requires coverage of enteric organisms and anaerobes. The most common associated organisms include Escherichia, Klebsiella, and Enterobacter species. Single-drug or multidrug regimens are available. Piperacillin-tazobactam is the only single agent listed that will cover all necessary organisms. Treatment for ascending cholangitis is hydration, intravenous antibiotics, and endoscopic biliary drainage followed by cholecystectomy. Severe symptoms demand emergency bile duct decompression and relief of obstruction.
Ultrasound findings of acute cholecystitis?
Acute cholecystitis is almost always due to cystic duct obstruction by a gallstone and is associated with the ultrasound findings of echogenic material (gallstones) with posterior acoustic shadowing (because gallstones are generally quite dense and solid they are hyperechoic, leading to posterior shadowing), pericholecystic fluid, and a thickened gallbladder wal
What are the symptoms of a choledochal cyst? types? (loosely know this)
abdominal pain and recurrent cholangitis are the most common presentation of a choledochal cyst. There are 6 types of choledochal cysts (listed below). The patient has a type I cyst with a classic fusiform dilation of the common bile duct. The abdominal pain is usually in the right upper quadrant, and many patients have gallstones either in the cyst or the gallbladder. Magnetic resonance cholangiopancreatography has become the diagnostic procedure of choice. Choledochal cysts have an increased risk of malignancy. The risk increases with age. It is recommended to have surgical removal of the cyst to prevent the development of malignancy.
The 6 types of choledochal cysts are as follows:
Type I: Fusiform dilation of the common bile duct. Treatment is complete cyst excision with Roux-en-Y hepaticojejunostomy reconstruction.
Type II: Simple diverticulum of the extrahepatic biliary tree. Treatment is complete cyst excision and primary closure of the defect with or without placement of a T-tube.
Type III: Cystic dilation of the intraduodenal portion of the extrahepatic common bile duct; also known as a choledochocele. Treatment is endoscopic retrograde cholangiopancreatography with endoscopic unroofing of the choledochocele and sphincterotomy of the common bile duct.
Type IV: Involves multiple cysts of the intra- and extrahepatic biliary tree. Treatment is resection of the involved segments if possible and Roux-en-Y hepaticojejunostomy.
Type V: Isolated intrahepatic biliary cystic disease, also known as Caroli disease.
Type VI: Isolated cystic duct cyst.
