Disorders of the gallbladder Flashcards
Cholelithiasis
Cholelithiasis is simply the presence of
gallstones, which form in the biliary tract,
usually in the gallbladder.
_____ - the presence of 1 or
more gallstones in the common bile duct.
Choledocholithiasis
Factors affecting Gallstone
formation:
● Stasis, change in bile concentration (high
cholesterol), and decreased gallbladder motility.
● CCK causes the gallbladder to contract and relaxes the sphincter of Oddi
Cholelithiasis pathophysiology
○ Most gallstones are cholesterol based, which are most commonly radiolucent on X-ray
○ Patients with elevated risk of developing gallstones:
■ “The Four F’s.
“Classic” risk factors for stone formation (the four F’s)
● Female- Estrogen increases risk of gallstones
● Forties- Premenopausal spikes in estrogen
● Fertile- Pregnant women have higher estrogen
● Fat- May be related to cholesterol levels in bile
S/S of Cholelithiasis
● If symptoms develop, it is secondary to the lodging of gallstones, leading to
blockage of bile flow.
○ Sporadic and unpredictable episodes of biliary colic (sudden pain)
■ Pain often begins shortly after eating
If the stone is in the ampulla of vater, _____
Gallstone Pancreatitis can develop.
Pima indian tribe and gall stones
80% will have gallstones byy the age of 35
Cholelithiasis diagnosis
Ultrasound is the diagnostic test of choice
Other imaging If Choledocholithiasis is suspected
■ Endoscopic Retrograde Cholangiopancreatography (ERCP)
■ Magnetic Resonance Cholangiopancreatography (MRCP)
Magnetic Resonance Cholangiopancreatography (MRCP)-
○ A non-invasive imaging technique that
allows for visualization of the biliary tree
and pancreatic ducts.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
○ ERCP combines Endoscopy with
Fluoroscopy (X-ray with contrast dye)
to evaluate the biliary tree and
pancreatic ducts.
○ It is moderately invasive and does
administer radiation, so it is becoming
secondary to MRCP unless there is
high likelihood that treatment will be
needed during the study.
■ Ex: Choledocholithiasis
If a gallstone is
immediately available, the
stone can be extracted
during this procedure
ERCP
Cholelithiasis Management
As long as the patient is asymptomatic, treatment is essentially expectant and watchful.
Cholecystectomy is usually the definitive treatment of choice for
Cholelithiasis
Cholecystitis
Inflammation of the gallbladder that occurs most commonly secondary to
cystic duct blockage by a gallstone.
● Can be acute or chronic.
● Gallstones are present in 90-95% of
cases - “Calculous Cholecystitis.”
Cholecystitis Pathophysiology (acute vs. chronic)
○ Acute Cholecystitis: Gallstone blockage in the cystic duct leads to
distended and tense gallbladder that may contain areas of ischemia with
necrosis, as well as possible purulent material.
○ Chronic Cholecystitis: Chronic irritation and inflammation of the gallbladder that continues over time, usually secondary to repetitive bouts of acute cholecystitis.
Cholecystitis S/S
○ The most common symptom is upper abdominal pain.
■ With acute cholecystitis, the pain often beings in the epigastric region, then localizes to the RUQ.
○ Pain is often colicky, can become constant as it progresses.
■ Sometimes refers to the right scapula/shoulder
○ Nausea and vomiting are frequently present.
○ Often made worse by eating (especially greasy foods).
Clinical Clues of Cholecystitis
○ Acute calculous cholecystitis is commonly seen in patients with the 4 Fs
○ Murphy’s Sign
○ Abdominal guarding or rebound tenderness, are often present.
Lab tests may suggests hepatobiliary disease, but are not reliable
for diagnosis of _____
cholecystitis.
Cholecystitis diagnosis
○ Ultrasound is the preferred initial
imaging test
○ Hepatobiliary Iminodiacetic Acid (HIDA) Scan
○ CT abdomen with contrast or MRI with
contrast can identify cholecystitis, but are not recommended as initial studies
What will you see on ultrasound for Cholecystitis
■ Gallbladder wall thickening and
pericholecystic fluid are sonographic
evidence of cholecystitis.
■ Presence of cholelithiasis in combination with the sonographic
Murphy’s Sign is a highly sensitive US
finding.
Hepatobiliary Iminodiacetic Acid (HIDA) Scan
also known as Cholescintigraphy. Usually performed second, if the Gallbladder
Ultrasound is equivocal (IE, to confirm or clarify).
■ Nuclear imaging procedure to evaluate function of gallbladder.
Management of cholecystitis
○ Initial treatment may involve bowel rest, IV hydration, analgesia,
antiemetics, and IV antibiotics.
○ Uncomplicated cholecystitis can be treated on outpatient basis, often
including Levofloxacin and Metronidazole, and antiemetics.
○ Surgical intervention is often performed, emergently if complications are
present- Laparoscopic Cholecystectomy is standard of surgical care.
Cholecystectomy
surgical removal of the gallbladder
T/F Laparoscopic Cholecystectomy is preferred over the open procedure
T
When may a cholecystectomy need to convert from laproscopic to open?
○ Significant bleeding that is difficult to
control laparoscopically
○ Rupture of the gallbladder
○ Difficulty due to size of liver
○ Unexpected pathology
Outpatient vs. inpatient Cholecystectomy
● If the procedure was done as a planned, elective procedure, it’s
generally done as an outpatient with discharge home the same day.
○ Generally regain normal level of life within 1 week
● If the procedure was performed emergently/urgently (and was not
planned), the patient generally remains in the hospital for a few days
for monitoring and IV antibiotics.
Acute Cholangitis
Acute cholangitis is an acute infection of
the biliary tree
It is very dangerous and potentially deadly because it can lead to sepsis
Acute Cholangitis pathophysiology
○ These bacteria are able to proliferate in
the biliary tree when a significant
obstruction occurs.
■ “Ascending cholangitis”
○ Most common cause of the obstruction is choledocholithiasis
Acute Cholangitis S/S
○ Classic presentation is that of Charcot’s
Triad (present in 50-70% of cases):
■ RUQ pain (90%)
■ Jaundice (80%)
■ Fever (95%)
Reynold’s Pentad:
■ Altered Mental Status
■ Hypotension/shock
Acute Cholangitis diagnosis
○ Although a clinical diagnosis for the
most part, Ultrasound is the
diagnostic tool that is most useful.
■ Biliary dilation or stones
○ Lab studies:
■ CBC will show leukocytosis
■ Elevated bilirubin levels
■ Elevated AST/ALT
○ ERCP can be diagnostic and therapeutic, but should be avoided until
the patient medically stable.
Management of acute cholangitis
○ Broad-spectrum IV antibiotics are necessary.
○ Correction of fluid and electrolyte disturbances.
○ With severe cholangitis with obstruction, Endoscopic Biliary
Decompression may be necessary.
Primary Sclerosing Cholangitis
● PSC is a chronic, progressive thickening of the walls of the bile ducts.
● The etiology is essentially unknown (autoimmune?), although there is a very strong correlation to Inflammatory Bowel Disease, especially Ulcerative Colitis (UC).
Primary Sclerosing Cholangitis pathophysiology
○ A continual underlying inflammation
of the walls of the ducts is the likely
explanation for the development of
fibrosis and strictures.
● The disease generally progresses until it eventually culminates in portal
hypertension, cirrhosis with complications, and liver failure.
● PSC patients are high risk for development of cholangiocarcinoma.
Primary Sclerosing Cholangitis s/s
○ Jaundice and pruritus are the most common presenting features.
○ Other signs and symptoms include:
■ Fatigue/malaise
■ Weight loss
■ Dull right upper quadrant pain
■ Hepatomegaly and/or splenomegaly are common
○ Recurrent febrile bacterial cholangitis occur in about 10-15% of patients.
Primary Sclerosing Cholangitis Diagnosis
○ ERCP (or MRCP) demonstrate
sclerotic appearing biliary ducts.
Although not necessary for diagnosis,
liver biopsy may reveal “onion skin”
fibrosis of the bile ducts with
Primary Sclerosing Cholangitis
Primary Sclerosing Cholangitis managment
No great options
■ Ursodiol is a PO medication that can be used in combination with
ERCP (endoscopic duct dilation).
○ The median length of survival after
diagnosis is 12 years.
○ Liver transplantation is the only
treatment that appears to extend life or
change the prognosis.
Gallbladder Cancer
Gallbladder Cancer is a rare malignancy that
develops in patients with a long history of
chronic gallbladder inflammation
The average age of diagnosis for gallbladder cancer in the US is between ____
62 and 66 years.
Gallbladder Cancer S/S
○ Signs and symptoms may not develop until late stage gallbladder
cancer
○ Typical symptoms include: (Seem familiar?)
■ Jaundice
■ RUQ aching abdominal pain
■ Low-grade fever
■ Nausea with vomiting
■ Bloating
■ Small percentage may have RUQ mass
Gallbladder Cancer diagnosis
○ Ultrasound is the standard for initial study of
choice; may show mass in 50-75% of cases.
○ CT with contrast may show the tumor better
and will shed light on any mets.
○ ERCP may establish the diagnosis by obtaining
cytology samples of the bile.
Gallbladder cancer and surgery
Complete surgical resection is the only chance for a cure, however,
most have metastasized to the local or distant nodes early
Cholangiocarcinoma
A malignancy of the biliary ducts that may occur anywhere from the small
upper ducts down to the Ampulla
There are essentially two anatomic regions for cholangiocarcinoma
○ Intrahepatic tumor
○ Extrahepatic tumor
More than 90% of cholangiocarcinoma are _____
adenocarcinomas
Cholangiocarcinoma etiology
largely unknown, but likely
attributable to chronic ductal inflammation.
○ Association with Primary Sclerosing
Cholangitis
Cholangiocarcinoma S/S
○ Significant Jaundice is the most common manifestation.
○ Clay-colored stools (Acholic) and bilirubinuria (dark urine).
○ Pruritus is common with the jaundice.
○ Weight loss or abdominal pain are variable
Cholangiocarcinoma tumor marker
CA 19-9
ERCP with brush cytology provides
tissue to make the definitive diagnosis of
Cholangiocarcinoma
Overall survival of Cholangiocarcinoma
6 months after diagnosis
