Gallbladder 10-27 (1) Flashcards
CHOLELITHIASIS definition.
stones in gallbladder.
CHOLELITHIASIS 3 symptoms?
Colicky RUQ pain. Radiates to the shoulder. Worse with fatty foods.
CHOLELITHIASIS diagnosis?
RUQ Ultrasound
CHOLELITHIASIS 2 treatment?
Cholecystectomy elective.
Ursodeoxycholic acid for nonsurgical patients.
Cholecystitis. definition?
stones in cystic duct, causing inflammation of gallbladder.
Cholecystitis. CP? what sign?
Constant RUQ pain, positive Murphy’s sign, fever, leukocytosis.
Cholecystitis. what is murphy sign? (also known as Sweeney’s sign.
stops breathing when palpated
Cholecystitis. diagnosis? first method?
US: pericholecystic fluid, thickened gallbladder wall, and gall stones.
Cholecystitis. diagnosis. if US negative?
HIDA scan: failure of filling of gallbladder.
hepatobiliary iminodiacetic acid (HIDA) scan
Cholecystitis. treatment?
NPO, IVF
IV Abx; if complicated; signs of sepsis.
Urgent cholecystectomy.
Nonsurgical patient: cholecystostomy & bile acid dissolution therapy (ursodeoxycholic acid) for 6 to 24 months.
Cholecystitis. treatment if nonsurgical patients?
Nonsurgical patient: cholecystostomy & bile acid dissolution therapy (ursodeoxycholic acid) for 6 to 24 months.
2 cholecystitis complications?
Bile acid diarrhea due to fistulas with the large bowel.
Gallstone ileus: biliary-enteric fistula with small bowel.
cholecystitis. gallstone ileus. CP?
CP: Nausea and vomiting; Abdominal distention; Hyperactive bowel sounds; Inability to pass stool and flatus; Intermittent tumbling obstruction with diffuse abdominal pain and vomiting until finally lodging in the ileum.
cholecystitis. gallstone ileus. diagnosis? 2
X-ray
CT
cholecystitis. gallstone ileus. what shows xray?
Dilated bowel loops, multiple air-fluid levels, and pneumobilia (air in biliary tree).
cholecystitis. gallstone ileus. CT scan is confirmative. what seen?
Pneumobilia. Gallbladder wall thickening. Obstructing stone.
cholecystitis. gallstone ileus. management?
Surgical removal of stone (enterolithotomy) and cholecystectomy.
Possible bowel resection.
EMPHYSEMATOUS CHOLECYSTITIS, definition?
gallbladder infection due to gas-producing mo/s
Emphysematous cholecystitis. CP?
Fever, RUQ pain, nausea/vomiting
Crepitus in abdominal wall adjacent to gallbladder, Ileus (decr. Or absent bowel sounds)
Emphysematous cholecystitis. diagnosis. what method preffered
CT is preferred over US
Emphysematous cholecystitis. 2 complications?
gangrene and perforation
Emphysematous cholecystitis. risk factors?
DM
vascular compromise
immunosupression
Emphysematous cholecystitis. what is seen on imaging? CT
air-fluid levels in gallbladder, gas in its wall
Emphysematous cholecystitis. labs?
unjonjugated hyperbilirubinemia, mildly elevated aminotransferases
Emphysematous cholecystitis. what cultures?
cultures with gas forming Ecoli, clostridia
Emphysematous cholecystitis. treatment?
Emergent cholecystectomy
broad abs with clostridium coverage (eg ampicillin-sulbactam).
Acalculous cholecystitis.
Never had a gallbladder disease before.
Diagnosis by a high degree of suspicion and imaging studies.
.
Acalculous cholecystitis.
risk factors?
Severe trauma or recent surgery
Prolonged fasting or TPN
Critical illness (sepsis, ICU)
Acalculous cholecystitis. clinical?
Fever, leukocytosis, incf. LFTs, RUQ pain
Jaundince and RUQ mass is less common
Acalculous cholecystitis. diagnosis?
US preffered
HIDA or CT if needed
Acalculous cholecystitis. treatment?
Enteric abs coverage
Cholecystostomy for initial drainage
Cholecystectomy one clinically stable
Management of gallstones.
stones without symptoms?
No treatment required in most patients
Management of gallstones.
stones with typical biliary colic symptoms? 2
elective laparoscopic cholecystectomy
possible ursodeoxycholic acid in poor surgical candidates
Management of gallstones.
complicated gallstone disease *
*acute cholecystitits, choledocholithiasis, gallstone pancreatitis.
cholecystectomy within 72 h
what in included in complicated gallstone disease?
*acute cholecystitits, choledocholithiasis, gallstone pancreatitis.
Postcholecystectomy syndrome. when manifests?
Postoperative (early) or months to years (late) after cholecystectomy.
Postcholecystectomy syndrome. due to 2 groups of reasons?
Can be due to biliary (retained CBD or cystic duct stone, biliary dyskinesia)
OR
extra-biliary (pancreatitis, PUD, CAD).
Sphincter of Oddi dysfunction; either stenosis or dyskinesia (SOD). Can be triggered by opioid medication (morphine).
Postcholecystectomy syndrome. CP?
Persistent abdominal pain. Dyspepsia.
Postcholecystectomy syndrome. labs? transferazes visokios
Elevated ALP.
Abnormal aminotransferases.
Dilated CBD on abdominal US. SOD –> SOD manometry.
SOD = stenosis or dyskinesia
Postcholecystectomy syndrome. management?
Endoscopic US, ERCP, or MRCP.
Directed at causative agent.
SOD –> sphincterotomy.
Choledolithiasis. definition?
stone in common bile duct
Choledolithiasis. CP?
C/P: Gallstone pancreatitis. Hepatitis. Obstructive jaundice. Painful. Positive Murphy’s sign. Fever. Leukocytosis.
Choledolithiasis. diagnosis?
RUQ US: obstruction.
If negative –> MRCP.
Choledolithiasis. treatment?
Treatment: NPO. IVF fluids. IV Abx if complicated; sepsis.
Urgent ERCP: sphincterotomy & elective cholecystectomy.
Or urgent cholecystectomy.
Choledolithiasis. followup?
Follow up: ball-valve effect: stone goes up and down the duct; might show improvement but stone is still there so ERCP is required.
Acute cholangitis. etiology?
Ascending infection due to billiary obstruction
Acute cholangitis. CP?
fever, jaundice, RUQ pain (Charcot triad)
+/- hypotension, AMS (Reynolds pentad)
Acute cholangitis. labs?
Leukocytosis with a left shift.
Direct hyperbilirubinemia.
Elevated ALP.
Anion gap metabolic acidosis from lactic acidosis.
Acute cholangitis. what is Charcot triad?
fever, jaundice, RUQ pain (Charcot triad)
Acute cholangitis. what is Reynolds pentad?
fever, jaundice, RUQ pain (Charcot triad)
+/- hypotension, AMS (Reynolds pentad)
Acute cholangitis. diganosis? labs
Cholestatic liver function abnormalities:
–> incr. direct bilirubin, alkaline phosphatase
–> mildly incr. aminotransferases
Acute cholangitis. US/CT findings?
biliary dilation on US or CT
Acute cholangitis. treatment?
abs coverage of enteric bacteria
biliary drainage by ERCP within 24-48h
buvo abs pamineti:
Ciprofloxacin plus metronidazole.
Ampicillin/gentamicin plus metronidazole.
dar buvo papildomai prierasas:
Therapeutic and diagnostic: emergent ERCP. Other options: percutaneous transhepatic cholangiography and open surgical decompression.
Urgent cholecystectomy.
porcelain. definition?
Calcium-laden gallbladder wall with bluish color and brittle consistency.
Associated with chronic cholecystitis.
porcelain. CP?
Asymptomatic. RUQ pain. Firm and nontender RUQ mass in PE.
porcelain. diagnosis? xray and CT
X-ray shows a rim like calcification in the area of the gallbladder.
CT scan reveals a calcified rim in the gallbladder wall with central bile-filled dark area.
porcelain. treatment?
cholecystectomy
porcelain. Increased risk for gallbladder adenocarcinoma.
Cholangiocarcinoma. definition?
Malignancy of the bile duct epithelium.
Cholangiocarcinoma. risk factors?
Fibropolycystic liver disease. PSC.
Cholangiocarcinoma. CP?
Abdominal pain.
Weight loss. Hyperbilirubinemia.
Cholestatic liver enzyme pattern.
Hepatomegaly and palpable RUQ mass.
Cholangiocarcinoma. diagnosis? labs
Elevated CEA.
Elevated Ca19-9.
Normal AFP.
Cholangiocarcinoma. diagnosis instrumental?
Abdominal imaging: intrahepatic or CBD dilation and biliary mass.
EUS or ERCP required for diagnosis.
bile acid diarrhea. pathophysiology?
Unresorbed bile acids spill into the colon, resulting in mucosal irritation
-> bile acid enters terminal ileum too rapidly and overwhelms resorptive capacity (eg post cholecystectomy)
-> ileal disease impairs bile absorption (eg Crohn disease, abdominal radiation damage)
bile acid diarrhea. clinical? 3
Secretory diarrhea (eg fasting diarrhea, nocturnal episodes)
Bloating, abdominal cramps
Unremarkable serum and stool studies
bile acid diarrhea. treatment?
bile acid-binding resins (eg cholestyramine, colestipol)
