Billiary Colic Flashcards
What is biliary colic (pathogenesis)?
Occurs when a gallstone is transiently impacted in the cystic duct, no infection
What are the clinical features of biliary colic?
- Severe dull pain in epigastrum or RUQ for minutes to hours, has a crescendo-decrescendo pattern
- May present with chest pain
- Nausea and vomiting
- Often occurs at night or after fatty meal
- Radiate to right shoulder or scapula
- No peritoneal findings or systemic signs
What will you find on investigations for biliary colic (blood work)
- Normal: CBC, lytes, LFT’s bilirubin, amylase/lipase
What imaging modality would you use to investigate biliary colic? What will you find on positive exam?
U/S
- 95% specific for stones
- gallbladder wall thickening >4mm, edema (double wall), gallbladder sludge, pericholecystic fluid and sonographic murphy’s sign seen with cholecystitis
What is the treatment for biliary colic?
- Analgesia
- Rehydration
- Elective cholecystectomy
What are some risk factors for cholesterol (gallbladder) stone formation?
- Obesity
- Estrogen (multiparity, OCP)
- Terminal ileal resection or disease (ex. Crohn’s)
- Impaired gallbladder emptying
- Rapid weight loss (biliary stasis and rapid cholesterol mobilization)
What are some risk factors for the formation of pigment stones (caclium bilirubinate)
- Cirrhosis
- Chronic hemolysis
- Biliary stasis
Name 4 factors protective for gallstones
1) Statins
2) Vitamin C
3) Coffee
4) Exercise
What is an MRCP?
magnetic resonance cholangiopancreatography - MRI to evaluate biliary tract and pancreatic ducts
What is an ERCP?
Endoscopic retrograde cholangiopancreatography
- Scope going into biliary and pancreatic ducts is diagnostic and therapeutic
What is a HIDA scan?
hepatobiliary iminodiacetic acid scan
- nuc med scan where technetium 99 is injected and excreted in high concentrations into the bile allowing visualization of the biliary tree
What is PTC?
Per-cutaneous transhepatic cholangiography
- inject contrast into hepatic parenchyma and flouroscopy performed, used if ER/MR CP fails or is unavailable
What is acute cholecystitis?
Inflammation of the gallbladder resulting from sustained gallstone impaction in the cystic duct or Hartmann’s pouch
What is Hartmann’s pouch?
An out-pouching at the junction of the neck of the gallbladder and the cystic duct. Gallstones commonly are stuck here.
Clinical signs of acute cholecystitis?
- Often have a history of biliary colic
- Severe constant (hours to days) epigastric or RUQ pain
- Anorexia
- Nausea/Vomit
- Low grade fever (
What is Boa’s Sign?
Right subscapular pain
Which organisms tend to be involved in infections secondary to cholecystitis?
- E. coli (gram negative rod)
- Klebsiella (gram -ve rod)
- Enterococcus (gram positive cocci)
Treatment for acute cholecystitis?
- Admit, hydrate NPO
- NG tube if persistent vomiting from ileus
- Analgesia
- Antibiotics (cefazolin for uncomplicated)
- Cholecystectomy
What is acalculous cholecystitis?
cholecystitis in the absence of stone, typically due to gallbladder ischemia or stasis
What is choledocolithiasis?
Stones in the common bile duct
In choledocolithiasis what is a primary stone? what is a secondary stone?
Primary - formed in the CBD (indicates bile duct pathology such as sclerosing cholangitis, stricture)
Secondary - Formed in the gallbladder (85% of US cases)
What lab abnormalities will you see in Choledocolithiasis?
1) CBC - leukocytosis
2) Liver enzymes - AST, ALT elevated early in disease
3) Increase in bilirubin
4) ALP and GGT elevated later
Treatment of choledocolithiasis?
If no evidence of cholangitis ERCP for stone extraction, possibly followed by cholecystectomy
What is cholangitis?
- Obstruction of the CBD leading to biliary stasis, bacterial overgrowth, suppuration and biliary sepsis. May be life threatening
Which bacteria are often present in cholangitis (6)
- E.coli (gram -)
- Klebsiella (gram -)
- Psuedomonas (gram -)
- Enterococcus (gram +)
- B. fragilis (gram - rod)
- Proteus (gram - rod)
What is charcot’s triad?
1) Fever
2) RUQ pain
3) Jaundice
What is reynold’s pentad?
1) Fever
2) RUQ pain
3) Jaundice
4) Shock
5) Confusion
What labs would you order if suspecting cholangitis
- CBC - ^ WBC, L-shift
- LFT - obstructive picture (increased ALP, GGT, conjugated bili, mild increase AST, ALT)
- Lipase to rule out pancreatitis
