Disorders of Gallbladder and Biliary Tree Flashcards
What is Cholelithiasis
aka gallstones
hardened deposits of digestive fluid that form in the galbladder
what are complications of gallstones
cholecystitis
cholangitis
choledocholithiasis
gallstones pancreatitis
cholangiocarcinoma (rare)
what are risk factors for cholelithiasis
female
obesity
increased age
pregnancy/OCPs
American Indian ethnicity
western diet, TPN
Rapid weight loss
family hx
what are the pathways for gallstone formation
cholesterol supersaturation
excess bilirubin
gallbladder hypomotility or impaired contractility
What patients have decreased bile salt secretion
cystic fibrosis
what are black pigment stones
small, hard gallstones composed of calcium bilirubinate and inorganic CA salts
associated wtih alchol-related liver disease
what are brown pigment stones
soft and greasy, consisting of bilirubinate and fatty acids
- infection, infalmation, parasitic - rare in US
What is biliary sludge
precursor to cholelithiasis
consists of calcium bilirubinate, choesterol microcrystals and mucin
develops during gallbladder stasis
what is the clinical presentation of cholelithiasis
most asymptomatic
Biliary colic most common symptom - RUQ pain radiating to scapula (or down right arm), sudden onset, intense in 15min to 1 hour, remains steady then gradually resolves over 30-90 minutes (temporary obstruction)
What are the initial workup for cholelithiasis
CBC, CMP, PT/PTT< lipase, amylase, alk phos, tot bilirubin, UA (usually normal)
US first line and best imagine
What is a HIDA scan
Evaluation of cholelithiasis with radioactive tracer
what is the treatment of asymptomatic gallstones
counsel regarding symptoms and when to get medical tx
PO/Parenteral analgesia in ER/urgent care
diet changes to reduce chances of recurrent episodes
what are stone dissolution treatments for cholelithiasis
Actigall/ursodiol
what is the treatment of choice for symptomatic cholelithiasis
laparoscopic cholecystectomy
what is inflammation of the gallbladder that develops over hours, usually because of obstructing gallstone in cystic duct
acute cholecystitis
what are symptoms of acute cholecystitis
RUQ pain and tenderness; maybe fever, chills, n/v
what is the treatment for acute cholecystitis
usually ABX and cholecystectomy
what is the clinical presentation of acute cholecystitis
most with prior attacks of biliary colic or acute cholecystitis
severe RUQ pain > 6hours with bloating, foot intolerances, increased gas, n/v, pain in midback/shoulders
Murphys sign
what is the first test in the ED for acute cholecystitis
CT scan; r/o GB perforation or pancreatitis
what is the best test to detect gallstones and evaluate GB disease
Transabdominal gallbladder US
What is Acute acalculous cholecystitis
cholecystitis without stones
risks: critical illness, prolonged fasting/TPN, Shock, immune deficiency, vasculitis, children
what test is more helpful for acute acalculous cholecystitis
HIDA scan more helpful; failure to fill may indicate edematous cystic duct obstruction
what are complications of acute acalculous cholecystitis
if untreated, rapid progression to GB gangrene and perforation, sepsis, shock, peritonitis, mortality 65%
What is the treatment for acute cholecystitis
admit, iv analgesics, NPO, NG suction if vomiting, IV abx if concern for infection
cholecystectomy cures acute choecystitis and relieves biliary pain
what is Mirizzi syndrome
rare; stone impacted in cystic duct, compresses and obstructs CBD, causing cholestasis
What is cholecystoenteric fistula
rare; large stone erodes GB wall, creating fistula into small bowel; stone may pass freely or obstruct small bowel (gallstone ileus)
What is chronic cholecystitis
prolonged, subacute condition; mechanical or functional dysfunction of GB emptying
what is porcelain gallbladder
extensive calcification due to fibrosis
What is the classic montra for cholecystitis
fat, forty, fertile, female, (flatulant)
What is the clinical presentation of chronic cholecystitis
dull RUQ pain, radiate mid back/right scapula; usually associated with fatty food ingestion
c/o N/v, bloating, flatulence; usually later evenin
what is the classic physical exam of chronic cholecystitis
+ murphys sign
not acutely ill but uncomfortable
vitals usually WNL
What is the test of choice for the diagnosis of chronic cholecystitis
US
HIDA best to confirm acalculous cholecystitis
what is the treatment for chronic chollecystitis
laparoscopic cholecystectomy
milder/poor surgical candidates: strict low fat and low spice diets or Actigall (ursodiol)
what is choledocholithiasis
presence of stones within the common bile duct (CBD)
primary: form in bile duct
secondary: form in GB but migrate to bile duct
What is the clinical presentation of CBD stones
pain: colicky, RUQ, mod severity: intermittent and recurrent
episodic hx epigastric, RUQ pain
may have episodic icterus/jaundice; pruritis, n/v, clay-colored stools, tea-colored urine
What is Courvoisier’s sign
presence of palpable GB (GB dilation due to obstruction of CBD)
What bloodwork is done for choledocholithiasis
CMC/CMP
Lipase
INR/PT
what is the diagnostic test of choice for choledocholithiasis
abdominal US
what is the treatment for choledocholithiasis
ERCP (with spincterotomy to remove stone/s)
What is acute cholangitis
CBD obstruction allows bacteria to ascent from duodenum
what is charcot triad
abdominal pain, jaundice, fever or chills
(cholangitis)
what is reynolds pentad
confusion, hypotension, abdominal pain, jaundice, fever and chills
(cholangitis)
What is recurrent pyogenic cholangitis
characterized by intrahepatic brown pigment stone formation
occurs in southeast asia
sludge and bacterial debris in bile ducts
what is the treatment of acute cholangitis
emergency requiring aggressive supportive care and urgent removal of stones, endoscopically or sugically
abx likely acute
alternative for very ill: meropenem, ciprofloxacin plus metrinidazole
what is the treatment of recurrent pyogenic cholangitis
supportive care (broad-spectrum abx), eradicate any parasites and mechanically clear ducts of sotnes and debris via ERCP or surgically
what are the common organisms associated with acute cholangitis
gram negative (e.coli, klebsiella, enterobacter)
what is primary sclerosing cholangitis
chronic and progressive patchy inflammation, fibrosis, and strictures of bile ducts that has no known cause
80% have IBD, most often ulceratlive colitis
what procedure is indicated with primary sclerosing cholangitis
liver transplant
what is the pathophysiology of primary sclerosing cholangitis
progressive fibrosis around intrahepatic bile ducts lead to concentric and circumferential laminations
“onion skin” fibrosis
what is the clinical presentation of PSC
50% asymptompatic- dx after abnormal LFTs found when tested for other reasons
c/o RUQ pain, pruritis, fatigue, jaundice
development of symptomatic gallstoens and choledocholithiasiss
what are the subtypes of PSC
classic
small duct
associated with autoimmune hepatitis
what is seen on PE with PSC
hepatomegally, splenomegally, jaundice, excoriations from prurutis
fever, chills, RUQ pain, +/- jaundice; onset bacterial cholangitis
what is rerquired for diagnosis of PSC
US
cholangiography- multiple strictures and dilations in intrahepatic and extrahepatic bile ducts - ERCP
what is acute cholecystitis
stone lodged in cystic duct causes GB to become distended and inflamed; fever, RUQ pain and murphys sign
