Cholelithiasis/Cholangitis Flashcards
bile
general
Yellow-brown or yellow-green alkaline fluid continuously formed in the liver
~1 liter produced per day
Drains into the gallbladder for storage
Composed of:
Cholesterol (10%), bilirubin (1%), water, bile salts (70%), phospholipids (5%), and proteins (5%), electrolytes, and bicarbonate
bile
essential for? (3)
Digesting (emulsification) fats
Excreting cholesterol – how most of the cholesterol in the body is excreted
Antimicrobial activity
The Biliary Tree
general
Series of ducts within the liver, gallbladder, and pancreas that empty into the small intestine
Components:
intrahepatic (within the liver)
extrahepatic (outside the liver)
biliary tree
flow of bile
Gallbladder → cystic duct → common bile duct → addition of the pancreatic duct to the common bile duct → duodenum through the ampulla of Vater
Physiology of the Gallbladder
Store, concentrate, and when stimulated, releases bile into the duodenum via the common bile duct
Fatty foods and proteins entering the duodenum signal the release of cholecystokinin (CCK)
Cholecystokinin
Peptide hormone released by I-cells (i) located in the duodenum and jejunum
Two functions in relation to the gallbladder:
Stimulate the smooth muscle of the gallbladder to contract and release bile into the biliary tree
Signal the muscular sphincter of Oddi to relax
Cholelithiasis
general
One or more calculi (gallstones) in the gallbladder
Produced when there is an imbalance in the constituents of bile and biliary sludge secondary to gallbladder hypokinesis (bile is not flowing)
Gallstone classification (3)
Cholesterol stones
black pigmented stones
brown pigmented stones
Insoluble stones can lead to physical blockages in the biliary tree and beyond
Cholesterol stones
and RF
80% of stones
Most often associated with the risk factors - estrogen, obesity, multiparity, and advancing age
6 F’s mnemonic – female, fat, fertile, forty, fair, family history
Pigmented stones
Brown
Soft and greasy
Form secondary to infection, inflammation, or parasitic infestation in the biliary ducts
Pigmented stones
Black
Composed of calcium bilirubinate
Secondary to conditions that cause hemolysis (sickle cell anemia)
Radiopaque…visible on x-ray
Cholelithiasis
RF
Female sex
Obesity
Increased levels of estrogen (pregnancy)
Prolonged fasting
Low calorie, rapid weight-loss diets
Advanced age
Native Americans
Mexican-Americans
Family history of gallbladder disease
estrogen increases cholesterol stones
cholelithiasis
S/Sx
Often asymptomatic – “silent stones”
Biliary colic
Severe, sudden right upper quadrant pain lasting a few minutes to several hours
Postprandial
Nocturnal
Referred pain straight through to the back
Due to temporary obstruction (usually by stones) in the cystic duct or common bile duct
Nausea and vomiting
Abdominal bloating
should have NEGTIVE murphy sign and NO fever
cholelithiasis
Complications of Gallstones
Acute Cholecystitis
Gallstone pancreatitis
Choledocholithiasis- stone in common bile duct
Cholangitis- infection from obstruction
Gallstone ileus
Prolonged blockage of any biliary ducts can cause severe damage to the gallbladder, liver, or pancreas
cholelithiasis
Imaging
Ultrasound
First test to perform for RUQpain
Noninvasive and no radiation exposure
Sensitivity and specificity of 95% for detecting stones and sludge
Alternatives:
If ultrasound is equivocal or there is concern for a gallstone in the common bile duct
Endoscopic ultrasound for detection of small stones (< 3 mm)
Magnetic resonance cholangiopancreatography (MRCP)
cholelithiasis
Surgical Tx
Indications
Cholecystectomy
Most common method for treating symptomatic gallstones, asymptomatic large gallstones (>3 cm), and porcelain gallbladder
Types:
Open cholecystectomy
Laparoscopic cholecystectomy – 95%
Porcelain Gallbladder
general
Also known as a calcified gallbladder
Not a gallstonebut often found in conjunction with gallstones
Calcifications in thegallbladderwall, with mechanism the same as gallstones
Gallbladder wall becomes brittle, hard, and often takes on a bluish hue
Absences of Courvoisier’s sign
Increased risk ofgallbladder cancer
no murphy or fever. No courvoisier’s sign
cholelithiasis
lifestyle modifications
Meds
Dietary modification (↓ saturated fat intake; ↑unsaturated fatty acids,vitamin C)
Weight loss
Ursodiol
Stone dissolution agent
Effective for small, radiolucent stones (most likely composed of cholesterol) in a functioning non-obstructed gallbladder – 2 years of therapy
Candidates:
Declined surgery
High surgical risk (advanced age or concomitant medical disorders)
Prevention of stone formation in overweight patients losing weight quickly
Stones recur in 50% of patients within 5 years of discontinuing the medication
Choledocholithiasis
general
described as
Stones in the common bile duct
Described as:
Primary stones
Form in the common bile duct
Usually brown pigmented stones (associated with infection)
Secondary stones – 85%
Form in the gallbladder, but migrate to the common bile duct
Usually cholesterol stones
Residual stones
Stones missed at the time of cholecystectomy
Recurrent stones
Stones that develop in the common bile duct >3 years after surgery
Choledocolithiasis
S/Sx
Partial vs complete obstruction
Some stones pass asymptomatically into the duodenum
Partial obstruction:
Biliary colic: RUQ abdominal pain, nausea/vomiting
Complete obstruction:
Dilation of the common bile duct
Jaundice- disrupting flow of hepatic juices
Possibility of cholangitis – a bacterial infection
Possibility of gallstone pancreatitis – stones that obstruct the ampulla of Vater
Cholangitis
general
Inflammation of the bile ducts
Ascending cholangitis
Most common form – 85%
Bacterial infection resulting from an obstructing common bile duct stone
Cholangitis
Bacteria
Gram-negative bacteria ascends from the duodenum
Klebsiella species, E. coli, Enterobacter, Proteus, Serratia
KEEPS
cholangitis
labs
Pregnancytest in women of childbearing age
CBC – leukocytosis
↑ Liver function tests (bilirubin, ALP, AST, GGT, PT/INR, PTT)
Lactic acid
Blood cultures
lipase to rule out pancreatitis
Cholagnitis
Imaging
Ultrasound
Confirm the presence of a stone
Evaluate dilation of the common bile duct
Always start with US
MRCP (magnetic resonance cholangiopancreatography)
ERCP (endoscopic retrograde cholangiopancreatography)
Diagnostic and therapeutic
Gold standard for diagnosing cholangitis
IF THERE IS CHARCOT’S TRIAD THEN ERCP
choledocolithiasis
ERCP (endoscopic retrograde cholangiopancreatography)
Diagnostic and therapeutic
Gold standard for diagnosing cholangitis
Choledocholithiasis
Tx
meds and procedures
NPO
Pain management
IV antibiotics
Coverage for gram negatives andanaerobes
Cephalosporin or Fluoroquinolones+metronidazole
Piperacillin–tazobactam
ERCP and sphincterotomy
Allows for removal of a stone
Percutaneous transhepatic cholangiogram(PTC) with catheter drainage
Performed ifERCPis not available or unsuccessful
Elective laparoscopic cholecystectomy → prevent recurrence
Gallstone ileus
general
Occurs when a gallstone becomes lodged in the small bowel
>2.5 cm gallstones
Most common location is the terminal ileum
gallstone ileus
clin man
Clinical presentation
H/O recurrent RUQ pain
Abdominal distention
Nausea and vomiting
gallstone ileus
Dx and findings
Flat & upright abdominal radiographs
Rigler’s triad:
Pneumobilia (air in the bile ducts)
Evidence of a small bowel obstruction
Gallstone outside the gallbladder
gallstone ileus
Tx
NG tube
Surgical removal of the gallstone
A 74-year-old woman presents with 4 days of fever, chills, right upper quadrant abdominal pain, and jaundice.Her history is significant for cholelithiasis and chronic congestive heart failure requiring oxygen therapy. Her medications include digoxin, furosemide, and captopril.Laboratory testing demonstrates an elevated white blood cell count, alkaline phosphatase, and bilirubin levels. IV piperacillin/tazobactam and metronidazole are administered. Which of the following is the next best step in management?
A. Endoscopic retrograde cholangiopancreatography (ERCP)
B. Biliary lithotripsy
C. Emergent cholecystectomy
D. Hepatobiliary iminodiacetic acid (HIDA)scan
A
Which of these statements about bile is true?
A. It is an acidic fluid stored in the gallbladder
B. It is continually formed in the liver
C. About 500 mL is secreted daily
D. Its main function is emulsification of proteins
B
