Gallbladder Flashcards
Asymptomatic
Cramping and coming in “waves” due to abrupt RUQ or epigastric abdominal pain → 30 min - <6 hours
→ biliary colic - pain from impaction of stone at neck of gallbladder or cystic duct in RUQ, radiation to back and right scapula
Eating fatty meal = trigger for contraction → increased pain → relaxes → stone falls back, pain subsides
Pain peaks at about an hour
May have pain at night
N/V, bloating, belching
<1/week
cholelithiasis
gallstones can happen more often in those with RF:
Women
Age
Obesity
Hormone status
Ethnicity
Rapid weight loss
Diet + exercise help!
What’s the most common type of gallstone?
Cholesterol-crystalline cholesterol monohydrate - supersaturation of cholesterol (>80%)
Too much cholesterol or bilirubin, not enough bile salts, infrequent/incomplete emptying without inflammation
cholelithiasis
Discovered on imaging – abdominal/RUQ US
+/- Murphy sign
Cholescintigraphy (HIDA scan) if diagnosis remains uncertain following US - delayed/absent filling of intestine = CBD stone
Cholelithiasis
What are complications to consider with cholelithiasis?
Choledocholiathiasis, acute cholangitis, acute cholecystitis
How can you treat cholelithiasis?
Avoid triggers
NSAIDs can help: diclofenac
Cholecystectomy indicated for significant symptoms or
– calcified GB, gallstones >3 cm, Native American, candidate for bariatric surgery or cardiac transplantation
Those who cannot have surgery = ursodeoxycholic acid for 2 years
Epigastric, RUQ pain - severe, steady and continuous (>4-6 hours) after fatty or large meal, improving over 12-18 hours
Nausea, vomiting, anorexia, fever
Localized RUQ tenderness and guarding, movement increasing pain
Radiating to shoulder, interscapular area, right scapula/shoulder/back
acute cholecystitis
Acute inflammation of the gallbladder, often a complication of gallstones
Stone becomes lodged → inflammation
Or infection in immunocomp, vasculitis, meds (GLP-1)
E.coli most common bacteria
acute cholecystitis
PE:
+ Murphy’s sign
+ Boas sign (referred pain to right shoulder subscapular area)
Palpable gallbladder
Mild jaundice
Low grade fever + tachycardia
LABS: leukocytosis with a left shift, amylase mildly elevated
Transabdominal US
Thickening of GB wall >4mm
Presence of pericholecystic fluid
Sonographic Murphy’s sign
XR: radiopaque gallstones
HIDA scan (if not seen w/n 60 minutes, dose of morphine given to relax sphincter of Oddi)
→ nonvisualization of gallbladder 30 minutes after morphine is diagnostic
— If seen with morphine, abnormal gallbladder
acute cholecystitis
TOKYO GUIDELINES: 1+ local signs of inflammation and systemic signs of inflammation
→ local: Murphy sign, RUQ mass, pain, or tenderness
→ systemic: fever, elevated WBC, elevated CRP
acute cholecystitis
whats the treatment for acute cholecystitis?
All should be admitted with no oral feeding - NPO, IV fluids, pain control with NSAIDs (ketorolac), opioids AND:
IV antibiotics: 2nd/3rd gen cephalosporin (ceftriaxone, cefazolin, cefuroxime, cefotaxime) + metronidazole
OR fluoroquinolone + metronidazole for severe cases
Cholecystectomy within 24 hours of admission
chronic cholecystitis is almost always associated with
gallstones
Prolonged, subacute condition caused by mechanical/functional dysfunction of emptying of gallbladder from chronic inflammation of gallbladder
– repeat episodes of acute cholecystitis
– chronic irritation from stones
→ fibrosis and thickening, associated with cancer
chronic cholecystitis
CCK infusion to determine EF of gallbladder
– <35% EF = calculus or acalculous chronic cholecystitis
If normal EF but pain with CCK, + for gallbladder disease
chronic cholecystitis
RUQ or epigastric pain/tenderness (more prolonged, >6 hours), N/V, fever/chills, +/- jaundice, flushed skin, possible hepatomegaly, AMS
Pain resolution when stone is passed or removed
choledocholithiasis
Gallstones within common bile duct
Primary – de novo synthesis in CBD due to bile duct stasis -> bacterial overgrowth -> bilirubin deconjugation and breakdown -> formation of brown pigment stones
Secondary – formed in gallbladder and pass through bile duct
choledocholithiasis
BILE - choledocholithiasis
B - biliary imaging abnormalities
I - inflammatory test abnormalities
L - liver test abnormalities
E - exclusion of cholecystitis and acute pancreatitis
LABS: elevated AST/ALT, cholestatic pattern with increased alkaline phosphatase + GGT
US = dilated common bile duct
ERCP → diagnostic test of choice
choledocholithiasis
how do you treat choledocholithiasis
ERCP - endoscopic retrograde cholangiopancreatography (upper GI endoscope + XR to treat problem), remove stone, follow with lab cholecystectomy
Charcot triad = RUQ pain, spiking fever with chills, jaundice
Fever, shaking chills, jaundice, abdominal pain, RUQ pain
Reynolds pentad (acute suppurative cholangitis) = charcot triad + HOTN, AMS
acute cholangitis
acute cholangitis is common in those with
Hx of gallstones, cholecystectomy, pancreatitis, known biliary anomalies, travel to areas w/ biliary parasites
Inflammation of biliary tree from bacterial infection from biliary stasis/obstruction, often from junction w/ duodenum
acute cholangitis
First = transabdominal US → MRCP, EUS, ERCP
Early = AST and ALT elevated, leukocytosis, left shift
Later = liver tests elevated w/ increases in bilirubin, alkaline phosphatase, amylase, PT in cholestatic pattern (ALP>ALT, GGT)
RUQ US = TOC showing common bile duct dilation or stones, thickening of walls
CT
cholangiography – gold standard via ERCP or PTC
acute cholangitis
ABC - acute cholangitis diagnostic criteria
DIAGNOSTIC CRITERIA:
A: systemic inflammation
Fever > 38 or shivering
WBC <4k or >10k
B: cholestasis
Bilirubin >2
Raised cholestasis parameters
C: imaging
Bile duct dilation >7mm
Evidence of stone or obstruction
How do you treat acute cholangitis?
Endoscopic emergency!
Admit!
Urgent ERCP w/ stone extraction
check liver function prior
Ciprofloxacin + metronidazole
Severe disease:
IV pip/taz OR carbapenem
Emergent decompression of bile duct via ERCP for septic patients or those who fail to improve with abx after 12-24 hours
Lab cholecystectomy
Progressive, obstructive jaundice, fatigue, anorexia, pruritus, indigestion
Hepatosplenomegaly
primary sclerosing cholangitis
primary sclerosing cholangitis is common with
IBD (but less if smoker) – mostly UC
Familial
Male
Fibrosis and strictures of biliary system from chronic and diffuse inflammation
primary sclerosing cholangitis
LABS: vitamin deficiency, hyperbilirubinemia, elevated LFTs
Perinuclear ANCA and Rh factor
Cholestatic pattern = increased alkaline phosphatase + GGT
Diagnostic = MRCP → “beaded” appearance
Liver biopsy if MRCP is not confirmatory → periductal or “onion skin” fibrosis
primary sclerosing cholangitis
how do you treat primary sclerosing cholangitis?
IV ciprofloxacin
Strictures = endoscopic procedure w/ dilation or stent placement
Cholecystectomy
Liver transplant for patients w/ cirrhosis and clinical decompensation
