Colecistitis Aguda y Coledocolitiasis

Question 1

Criterios de colecistitis moderada

Answer 1

Grade II (moderate) acute cholecystitis “Grade II” acute cholecystitis is associated with any one of the following conditions:

1. Elevated WBC count (>18,000/mm 3 )
2. Palpable tender mass in the right upper abdominal quadrant
3. Duration of complaints >72 h a
4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)

Question 2

Criterios de colecistitis grave

Answer 2

Grade III (severe) acute cholecystitis “Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems:

1. Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 lg/kg per min, or any dose of norepinephrine
2. Neurological dysfunction: decreased level of consciousness
3. Respiratory dysfunction: PaO 2 /FiO 2 ratio <300
4. Renal dysfunction: oliguria, creatinine >2.0 mg/dl
5. Hepatic dysfunction: PT-INR >1.5
6. Hematological dysfunction: platelet count <100,000/mm 3

Question 3

Criterios diagnósticos de colecistitis aguda

Answer 3

A. Local signs of inflammation etc.

(1) Murphy’s sign, (2) RUQ mass/pain/tenderness

B. Systemic signs of inflammation etc.

(1) Fever, (2) elevated CRP, (3) elevated WBC count

C. Imaging findings Imaging findings characteristic of acute cholecystitis

Suspected diagnosis: one item in A + one item in B
Definite diagnosis: one item in A + one item in B + C

Question 4

Hallazgos en imagen de colecistitis aguda

Answer 4

The generally accepted imaging findings of acute cholecystitis are:
Thickening of the gallbladder wall (≥4 mm)
Enlargement of the gallbladder (long axis ≥8 cm, short axis ≥4 cm)
Gallstones or retained debris
Fluid accumulation around the gallbladder
Linear shadows in the fatty tissue around the gallbladder

Question 5

Estudio recomendado para colecistitis gangrenosa

Answer 5

TC o RMN contrastadas

Question 6

Hallazgos en imagen de colecistitis gangrenosa

Answer 6

Gangrenous cholecystitis exhibits specific findings on dynamic CT, including:
Irregular thickening of the gallbladder wall
Poor contrast enhancement of the gallbladder wall (interrupted rim sign)
Increased density of fatty tissue around the gallbladder
Gas in the gallbladder lumen or wall
Membranous structures within the lumen (intraluminal flap or intraluminal membrane)
Peri-gallbladder abscess

Question 7

El signo del borde interrumpido tiene valor predictivo negativo de 95%. V/F/NS

Answer 7

Verdadero pero tiene sensibilidad de 73%

Question 8

El US tiene alta sensibilidad para identificar gas en la pared de la vesícula biliar. V/F/NS

Answer 8

Falso. Es difícil distinguirlo de la vesícula de porcelana o del aire intraluminal. Se requiere TC para diagnóstico de colecistitis enfisematosa la cual tiene alta sensibilidad.

Question 9

Coledocolitiasis: valor predictivo negativo de PFH normales es…

Answer 9

97%

Question 10

US de HVB, tiene sensibilidad de 22-55% para coledocolitiasis. V/F/NS

Answer 10

Verdadero, es muy baja. Pero su sensibilidad para dilatación del colédoco es 77-87%

Question 11

En paciente con vesícula biliar intacta, la presencia de dilatación de vía biliar sugiere altamente probable coledocolitiasis cuando es mayor a cuantos milímetros:

Answer 11

> 8 mm

Question 12

Litos biliares que tienen mayor riesgo de coledocolitiasis
A. <5 mm
B. 5-10 mm
C. >10 mm

Answer 12

Múltiples litos <5 mm son los de mayor riesgo

Question 13

Predictor más fuerte de la existencia confirmada de coledocolitiasis:

Answer 13

Presencia de coledocolitiasis en US

Question 14

Predictores MUY FUERTES de coledocolitiasis:

Answer 14

Very strong

CBD stone on transabdominal US
Clinical ascending cholangitis
Bilirubin >4 mg/dL

Question 15

Predictores FUERTES de coledocolitiasis

Answer 15

Dilated CBD on US (>6 mm with gallbladder in situ)

Bilirubin level 1.8-4 mg/dL

Question 16

Predictores MODERADOS de coledocolitiasis

Answer 16

Abnormal liver biochemical test other than bilirubin
Age older than 55 y
Clinical gallstone pancreatitis

Question 17

Como se define un paciente con alta probabilidad de coledocolitiasis?

Answer 17

1 predictor muy fuerte o 2 predictores fuertes

Cuando no tienen ningún predictor es bajo
Cuando tienen 1 fuerte o algún moderado solamente es intermedio

Question 18

Paciente con alto riesgo de coledocolitiasis, que estudio requiere?

Answer 18

CPRE prequirúrgica

Question 19

Paciente con riesgo intermedio de coledocolitiasis, qué opciones de estudio tiene a continuación?

Answer 19

1. Colangiografía intraoperatoria, US intraoperatorio

2. US endoscópico pre quirúrgico o colangiorresonancia pre quirúrgica

Question 20

Paciente con colecistitis aguda y riesgo moderado de coledocolitiasis. Le hicieron colangiorresonancia y tiene coledocolitiasis. Qué le toca?

Answer 20

CPRE pre quirúrgica

Question 21

Qué estudio tiene mejor sensibilidad para coledocolitiasis? TC o US?

Answer 21

TC. Conventional (nonhelical) CT has historically demonstrated better sensitivity for choledocholithiasis than transabdominal US when composite diagnostic criteria are used (eg, the inclusion of indirect signs such as ductal dilation), although direct visualization of stones has not exceeded 75%. 45 Helical CT has shown improved performance over conventional CT for choledocholithiasis, with 65% to 88% sensitivity and 73% to 97% specificity.

Question 22

La sensibilidad de la colangiorresonancia es mayor que otros estudios (USE o CPRE) para litos <5 mm en coledocolitiasis. V/F/NS

Answer 22

Falso. MRC has 85% to 92% sensitivity and 93% to 97% specificity for choledocholithiasis detection, as assessed in 2 recent systematic reviews. However, the sensitivity of MRC seems to diminish in the setting of small (<6 mm) stones and has been reported as 33% to 71% in this clinical subset

Question 23

La sensibilidad del US endoscópico sigue siendo alta para coledocolitiasis a pesar del tamaño pequeño de los litos del colédoco. V/F/NS

Answer 23

Verdadero. Two meta-analyses, each composed of more than 25 trials and more than 2500 patients, reported an 89% to 94% sensitivity and 94% to 95% specificity of EUS for detecting choledocholithiasis, with ERC, IOC, or surgical exploration used as criterion standards. EUS remains highly sensitive for stones smaller than 5 mm, and its performance does not seem adversely affected by decreasing stone size

Question 24

Complicación más común de CPRE:

Answer 24

Pancreatitis. The risks of ERC include pancreatitis (1.3%-6.7%), infection (0.6%-5.0%), hemorrhage (0.3%-2.0%), and perforation (0.1%-1.1%) in prospective series of unselected patients. However, several patient variables (eg, young age, female sex) have been identified that serve as risk factors for pancreatitis; similarly, coagulopathy increases bleeding risk and immunosuppression increases the risk of infection at ERC. Thus, risk estimates must be individualized to the patient.

Question 25

Pacientes con pancreatitis biliar que se benefician de CPRE temprana:

Answer 25

Evidencia de colangitis (evidencia más fuerte) o sospecha de coledocolitiasis (evidencia menos fuerte) solamente.

In summary, in the absence of clear evidence of a retained stone, there does not seem to be a role for early ERC in the evaluation and management of patients with mild ABP. Conversely, in patients with ABP and concomitant cholangitis, early ERC is strongly recommended given the observed benefits in morbidity and mortality. Data are conflicting as to the benefit of early ERC in patients with predicted severe ABP or in ABP with clinical evidence of biliary obstruction when acute cholangitis is absent.

Question 26

Criterios de Charlson y ASA-PS para colecistectomía temprana en grado I y II:

Answer 26

Charlson 5 o menos, ASA-PS 2 o menos. Cuando es Charlson 6 o más o ASA 3 o más se sugiere retrasar la colecistectomía

Question 27

Factores de riesgo para retrasar colecistectomía en colecistitis aguda grado III:

Answer 27

Factores negativos: disfunción respiratoria (PAFI <300), disfunción neurológica, ictericia (BT >2.0)
Charlson 4 o más
ASA 3 o más puntos

Question 28

En colecistitis grado III, cuáles son las fallas orgánicas de buen pronóstico?

Answer 28

Disfunción circulatoria o renal que resuelven rápidamente con el manejo médico inicial.

Question 29

Punto de corte para no hacer colecistectomía laparoscópica temprana en cirrosis:

Answer 29

Child C o MELD 18 o más. Se recomienda realizar primero colecistostomía