Calculous Biliary Disease Flashcards
Which hormone is responsible gallbladder constriction and therefore for biliary colic
CCK - Cholecystokinin
synthesized and secreted by enteroendocrine cells in the duodenum. Its presence causes the release of digestive enzymes and bile from the pancreas and gallbladder, respectively, and also acts as a hunger suppressant.
What percentage of patients with asymptomatic gallbladders stones will develop symptoms?
Will develop complications?
20-30% will develop symptoms in 20 years.
About 1% will develop complications.
prophylactic cholecystectomy is not warranted in asymptomatic patient
which patients with asymptomatic bile stones can be treated With prophylactic cholecystectomy?
Why?
hemolytic anemias, such as sickle cell anemia.
Patients with a calcified gallbladder wall (known as porcelain gallbladder), those with large (>2.5 cm) gallstones, and those with a long common channel of bile and pancreatic ducts all have a higher risk of gallbladder cancer and should consider cholecystectomy.
In addition, patients with asymptomatic gallstones undergoing bariatric surgery may also benefit from cholecystectomy
Why does patients with asymptomatic gallstones undergoing bariatric surgery may also benefit from cholecystectomy?
Not only does rapid weight loss favor stone formation, but also, after gastric bypass, ERCP to remove common bile duct stones in ascending cholangitis is extremely challenging and usually unsuccessful.
What is the pathophysiologic mechanism of acute cholecystitis?
the primary pathophysiologic mechanism is unresolved cystic duct obstruction. The obstruction does not resolve, and inflammation ensues, with edema and subserosal hemorrhage. Infection of the stagnant pool of bile is a secondary phenomenon
What is acute emphysematous cholecystitis and gangrenous choelcystitis?
Without resolution of the obstruction, the gallbladder will progress to ischemia and necrosis. Eventually, acute cholecystitis becomes acute gangrenous cholecystitis and, when complicated by infection with a gas-forming organism, acute emphysematous cholecystitis
What signs on CT scan will suggest of an emphysematous cholecystitis?
Significant pericholecystic inflammatory changes and air in the gallbladder wall
Describe the Murphy sign
Arrest of inspiration with gentle pressure under the right costal margin
What is the Mirizzi syndrome?
When inflammation or a stone in the gallbladder neck leads to inflammation of the adjoining biliary system, with obstruction of the common hepatic duct.
Which type of imaging method has the highest sensitivity for acute cholecystitis?
US - sensitivity of 85% and specificity of 95%
CT - less sensitive than US
What are the first steps of treatment for acute cholecystitis
nothing by mouth, (IV) fluids and parenteral antibiotics
which types of organisms are common in cholecystitis?
gram-negative aerobes are the most common followed by anaerobes and gram-positive aerobes
How many patients with non operative management of cholecystitis will need surgery before the planned one?
20%
How should patients with acute cholecystitis and high operative risk be treated?
Some percutaneously placed cholecystostomy tube should be considered.
what primary choledocholithiasis is?
stones arise de novo in the bile duct.
generally from brown pigment stones, which are a combination of precipitated bile pigments and cholesterol.
more common in Asian populations
associated with a bacterial infection of the bile duct.
what is the name of a stone found in the CBD within 2 years after cholecystectomy?
Retained common duct stones.
Many common duct stones are clinically silent and may be identified only during cholangiography if it is performed routinely during cholecystectomy
Without pain or an abnormal liver function panel, cholangiography is usually not performed.
how many patients after cholecystectomy will present with a retained stone?
how many cases of choledocholithiasis will be found if cholangigraphy would have been done routinely?
1% to 2% of patients after cholecystectomy
will present with a retained stone.
When it is performed routinely, intraoperative cholangiography identifies choledocholithiasis in
approximately 10% of asymptomatic patients, suggesting that most choledocholithiasis remains clinically silent.
Charcot triad
Reynolds pentad.
Fever,right upper quadrant pain and jaundice - triad.
hypotension and mental status changes- pentad
US finding suggestive of choledocholithiasis
dilated bile duct (>8mm) in the presence of gallstones suggests choledocholithiasis, even if common duct stones are not documented ultrasonographically.
ndications for preoperative ERCP before cholecystectomy include:
cholangitis, biliary pancreatitis, limited experience of the surgeon with common duct exploration, and patients with multiple comorbidities.
what is the sensetivity and specificity of MRCP for the diagnosis of stones in the CBD?
What is it’s drawback compared to ERCP?
sensitive (>90%) almost 100% specificity
it does not provide a therapeutic solution (as in ERCP). A clear cholangiogram by MRCP eliminates the need for ERCP.
PTC is an invasive test with a complication rate similar to
that of ERCP (for choledocholithiasis).
when PTC is as effective as ERCP?
in patients with a dilated biliary ductal system
but less effective in the setting of a nondilated biliary tree.
how many patients will have recurrent symptoms of biliary tract disease when choledocholithiasis is managed by ERCP and sphincterotomy without cholecystectomy?
almost 50% of all patients will have recurrent symptoms more than one third of these patients eventually require cholecystectomy, older patients (>70 years) have only a 15% rate of symptom recurrence, so cholecystectomy can be offered selectively to this population of patients.
most cases of gallstone pancreatitis are self-limited. If, by clinical assessment, the pancreatitis is severe, what should be the treatment?
early ERCP to remove a stone that may not have passed
