chole's

Question 1

cholecystitis overview

Answer 1

acute inflammation of gallbladder
obstruction of the cystic duct

inflammatory response three factor

mechanical inflammation
due to increased pressure and distention

Chemical inflammation;
release of cytokines and other mediators

Bacterial inflammation:
Echoli, klebsiella, streptococcus and clostridium

Question 2

Acute cholecystitis

Answer 2

Inflammation develops behind the obstruction:>90% of cases.

Acalculous : RUQ pain and unexplained fevers

Signs and symptoms:
RUQ pain ( murphys sign)
fever
N/V
jaundice in 25% of cases
consider cholidithilisis or other

Labs:
Elevated WBC , LFT, Amylase

Imaging :
HIDA
high specific sensitivtiy
show gallbladdder dyskinesia

Gallbladder US:
more common used
results inflammation

Question 3

cholecystitis treatment

Answer 3

NPO
IV pain rx and abx
Rocephin 1 gram 24 hour + flagyl 500 Q 6
severe cases; Cipro 400 mg Q 12 + Flagyl
consult surgery

Laparoscopic cholecystectomy and IOC ( look at GBD with dye )
24-hour adm

Elected nonsurgical
monitor necrosis or cholangitis
diabetic, elderly obese, high risk

Gangrene or perforation
mandatory cholecycetomy

Question 4

Choledocholithiasis

Answer 4

15% of pt with stones have choledocholithiasis
increase with age
50% elderly with gallstones

bile duct stones originate in gallbladder
conspontaneous form in the bile duct

bile duct obstruction > 30 day s
liver damage
cirrhosis
hepatic failure
portal hypertension

Question 5

choledocholithisis findings and diagnosis

Answer 5

signs and symptoms;
abd pain
fever
N / V
elevated LFT

ultrasound and ct scan
dilated common bile duct
normal CBC diameter < 6

MRCP
identifies bile duct stone

Question 6

Choledocholithiasis treatment

Answer 6

consult GI
general surgery

ERCP:
sphincterotomy and stone extraction
stent placement
replacement / removed 3-6 months
risk for cholangitis and pancreatitis
procedure of choice
choledocholithiasis is complicated by acute cholangitis

Choledocholithiasis and cholecystitis
ERCP followed by a lap chole in 72 hours
cholecystectomy deferred two weeks without cholecystitis

postoperative abx
not routinely administered surgery
infected biliary tract infection
unysan 3 grams q 6 or zosyn IV q 6
rocephin 1 grm q 24

Question 7

Acute Cholangitis
overview

Answer 7

inflammation and infection of bile duct systerm
blocked duct in bile duct system
most common cause
gallstones or sludge
bacterial infection happens

lesser cause
primary sclerosing cholangitis

most common complications of a stricture
beign billary strictures
results of surgical anatomosis or injury

Question 8

cholangitis findings and diagnosis

Answer 8

infection of CBD
gram neg bacteria
E choli

SS
elevated WBC and LFT

Charcot Triad:
RUQ pain, fever, and jaundice

Renolds Pentad :
AMS and hypotension
bad prognosis
acute superlative cholangitis

mortality correlation
elevated bili prolonged PTT, liver abscess, and failed ERCP

Question 9

treatment of cholangitis

Answer 9

mild to moderate;
ciprofloxin 400 mg bid and flagyl 500 mg iv q 6 or
ampicillin 3 grams

severe
zosyn 33.7 -4 iv q 6
merrem 1 gram iv q 8
gentamycin 5-7 was added for severe sepsis

Billary enteric communication
add anaerobic coverage

surgical approach indicated
tachycardia , low albumin , elevated bilirubin, ALT, and WBC PT> 14
ERCP with sphincterotomy
within 24 hours

biliary stent
elective cholecystectomy after resolution of cholangitis