DSA 3: Gallbladder & Biliary Tree Flashcards
What part of the abd will hurt for GB dzs (what are all the DDx related to this)
RUQ: GB disease
- Acute cholecystitis
- Choledocholithiasis
- Ascending cholangitis
- Biliary dyskinesia
- Chronic cholecystitis
- Primary sclerosing cholangitis
How do you perform Murphy’s sign and what is a (+) sign
ask pt to exhale, examiner places hands below costal margin on R side at mid-clavicular line; ask pt to inspire
Pt stop breating in and winces w/ a “catch” in breath bc of inflammed GB palpation on inspiration
what are the types of stones in cholelithiasis
2 major types of gallstones =
- cholesterol (80%)- >50% cholesterol monohydrate
- pigment stones (20%)- primarily Ca2+ bilirubinate; brown stones form in bile duct bc of bacterial infxn (30-90% gallstones in Asians)
what are signs and symptoms of cholelithiasis
- biliary colic - severe steady ache in RUQ/epigastrium suddenly (often after meal)- occasionally radiate to R scapula
- N/V
what imaging and labs will confirm the diagnosis for cholelithiasis
Lab = normal or occasionally (mild/transient) elevation in bilirubin
Imaging: Ultrasongraphy is the best Dx test (RUQ US/hepatobiliary US) - stones seen as “acoustic shadow” that they cast
What are complications of cholelithiasis
cholecystitis, pancreatitis, cholangitis
what are RFs for gallstones
6 F’s: FHx, Fair, Fat, F, Fertile and Forty
Female, increase w/ age, obesity, pregnancy
american indians > mexican americans > non-hispanic whites > african-americans
DM, glucose intolerance, insulin resistance, hyper triglycerides, high intake of carb
MALE > FEMALE IF CIRRHOSIS & HEP C
What are protective factors for gallstones
low carb diet, high fiber diet, statins, ASA & NSAIDs
consumption of coffee (in women)
physical activity, cardioresp fitness
high intake Mg2+ and polyunsaturated & monosaturated fats (in men)
what are the 2 types/causes for acute cholecystitis
caculous: > 90% , impacted in the cyst duct; inflam GB develops behind the obstruction
acalculous: true cholecystitis + no stones; many acute illnesses, vascultitis, carcinoma, some GB infxns
What are signs and symptoms of acute cholecystitis
large fatty meals can cause acute attack
epigastric/RUQ tenderness (often w/ murphy’s sign)
sometimes jaundice
tea-colored urine or acholic stools
What labs and imaging help to diagnose acute cholecystitis
labs: leukocytosis, bilirubinemia, increase ALP & GGT
imaging: RUQ abd ultrasonography - GB wall thickening, pericholecystic fluid & sonographic Murphys sign
what are complications of acute cholecystitis
gangrene of the GB - may lead to GB perforation –> pericholecystic abscess –> generalized peritonitis
emphysematous cholecystitis (2ndary infxn w/ gas-forming organism)
What is essential for diagnosis of choledocholithiasis
what signs will be added to make you think ascending cholangitis
choledocholithiasis: stones in common bile duct (CBD) - most reliably detected by ERCP or EUS, N/V, biliary pain +/- jaundice
AC - fever, N/V, jaundice & leukocytosis, biliary pain +/- jaundice & gram-neg shock
What are signs/symptoms of choledocholithiasis
- freq recurring attacks of severe RUQ pain x hours
- chills/fever associated w/ severe pain
- Hx of jaundice associated with episodes of abd pain
(can lead to acute ascending cholangitis - AC)
what imaging/labs help to Dx choledocholithiasis
imaging: most direct, accurate = ECRP - help determine cause, location and extent of obstruction *do INR prior to ERCP*
labs: increase in AST/ALT, slow increase in ALP and GGT
how do you treat choledocholithiasis and ascending cholangitis
ERCP w/ sphincterotomy & stone extraction/stent placement
Cholecystectomy
What are Charcot Triad and Reynold pentad?
signs of ascending choliangitis
Charcot triad: RUQ + fever/chills + jaundice
Reynold pentad: Charcot triad + altered mental status (confusion) & hypotension; signify acute suppurative cholangitis and = endoscopic emergency
What are labs/imaging findings differentiate ascending cholangitis from choledocolithiasis
labs: (+) blood culture - e. coli, klebsiella, enterococcus
imaging: ERCP (diagnostic and therapeutic) (both)
what are characterisitics of ERCP
diagnostic & therapeutic : biliary tree, pancreatic duct
measure INR & pregnancy test prior to procedures
if using contrast - consider kidney fxn, Ck BUN/Cr
complications: acute pancreatitis
what are treatments for choleithiasis
asymp- monitor, recommend low fat diet.
Elective cholecystectomy for:
- symp pts (i.e., biliary colic despite low-fat diet)
- persons w/ previous complications of cholelithiasis
- presence of an underlying condition predisposing to an increased risk of complications (calcified or porcelain gallbladder)
- Pts with gallstones >3 cm
what is the treatment for acute cholecystitis
NPO, IV fluids/electrolytes, analgesia
ABx (add anaerobic converage if complications of gangrenous/emphysmatous chelecystitis)
SRG: urgent cholecystectomy - appropriate in most pts w/ suspected or confirmed complications
delayed SRG for pt w/ high risk of emergent SRG and where Dx in doubt
what is the treatment of choledocholithiasis
ERCP
Laparoscopic cholecystectomy
CBD stones are suspected prior to laparoscopic cholecystectomy, preoperative ERCP with endoscopic papillotomy and stone extraction is the preferred approach
CBD stones should be suspected in gallstone pts w/
- Hx of jaundice or pancreatitis
- abnormal LFT
- US evidence of a dilated CBD or stones in the duct
What is the Tx for cholangitis
urgent ERCP (stones removed)
treated like acute cholecystitis: NPO, hydration, analgesia and ABx; cholecystectomy
what is the treatment for PSC
no satisfactory therapy
cholangitis should be treated w/ urgent ERCP
Ursodeocycholic acid -improve liver tests but dont affect survivial
SRG relief may be needed but increase complications
liver transplant - for pt w/ end-stage cirrhosis
what is Laparoscopic cholecystectomy
= minimally invasive & is the procedure of choice for elective cholecystectomy [urgent gets lap or open depending on needs]
What is the Hx/PE of biliary dyskinesia
presents w/ symptoms similar to biliary colic - episodes of RUQ pain w/ nausea, severe & limit activites of daily like
What is diagnostic for biliary dyskinesia
clinical: RUQ pain similar to biliary colic
NORMAL US
Rome III diagnostic criteria for fxnal GB
normal liver enzymes, conjugated bilirubin and amylase/lipase
HIDA scan- abnormal- GB not seen –> stone in cystic duct/cholecystitis; (+) CCK-HIDA = abnormal ejection fraction is considered to be < 35-38% –> choleycystectomy
what is essential for diagnosis for chronic cholecystitis
chronic inflam of GB
almost always associated w/ gallstones
results from repeated acute/subacute cholecystitis or prolonged mechanical irritation
What are complications of chronic cholecystitis
Porcelain GB on x-ray
KUB-kidney/ureter/bladder x-ray/thoracic/lumbar x-ray - show incidental calcified lesion
increased risk of GB CA (poor prognosis)
how do you treat chronic cholecystitis
SRG if pt is symptomatic or if porcelain GB
What is the etiology of PSC
beads on a string
Males (20-50 yo)
associated w/ IBD (UC)
What is Hx/PE of PSC
clinical manifestation- pruritus, jaundice
fatigue, osteoporosis
can cause ascending cholangitis
what is diagnostic of PSC
cholestasis: increased ALP & bilirubin
ERCP: segmental fibrosis of the bile duct w/ accular dilations btn strictures (beads on a string)
liver Bx - periductal fibrosis (onion skinning)
what is the Tx/management for PSC
no proven therapy
symptomatic tx - steroids, bile salt chelators for pruritis (if acute treat like ascending cholangitis)
liver transplant
what are complications of PSC
increased risk of cholangiocarcinoma
associated w/ increase colon CA (from UC)
