Gallbladder Flashcards
Pt presents with steady pain in the RUQ for the last 4 hours associated with N,V, and fever.
acute cholecystitis
if a pt presents with jaundice, light colored stools, and dark tea colored urine what do they have
extrahepatic biliary obstruction
how does a pt with biliary colic present vs acute cholecystitis
biliary colic-uncomfortable and restless
cholecystitis-still because pain is aggravated by movement
what is murphy’s sign and what is it associated with
cessation of inspiration due to pain on deep palpation of the ruq when the visceral peritoneum overlying the gallbladder is inflamed
acute cholecystitis
courvoisier’s sign
nontender palpable gallbladder w jaundice that suggests underlying malignant disease such as carcinoma of the pancreas
what lab tests should be obtained
LFTs serum level of unconjugated bilirubin (hemolytic disorders);conjugated (extrahepatic obstruction) alkaline phosphatase (ALP)- syn by biliary tract epithelium; differentiate it from bone by heat stability or elevation of GGT (ALP/GGT >AST/ALT) INR- elev in pts w obstructive jaundice from malabsorption of vit K
what is the initial study of choice for pts w biliary disease
US
stones as small as 3mm in diameter
what does the finding of thickened gallbladder wall or pericholecystic fluid suggest
acute cholecystitis
how does the radionuclide biliary scan (HIDA scan) work
IV injection of 99techneitum derivative-> radionuclide excreted by the liver into bile in high concentrations –> enters gallbladder and duodenum
normal gallbladder begins to fill in 30m; if cant visualize common bile duct and duodenum wout filling of gallbladder in 4hr=cystic duct obstruction=acute cholecystitis
not useful for showing stones in either the gallbladder or common bile duct
leukocytosis,left shift, mild inc in AST/ALT/ALP, mild hyperbilirubinemia
acute cholecystitis
what is the initial management of acute cholecystitis
withholding oral intake
administering iv fluids
abx therapy
what bacteria is commonly assoc w acute cholecystitis
e choli
klebsiella
streptococcus faecalis
what is the tx for pts w acute cholecystitis who are poor surgical candidates
cholecystostomy- percutaneous placement of a tube under us guidance through the liver into the gallbladder to drain its contents
what is acute emphysematous cholecystitis
result from gas forming bacteria
will see air on xray
biliary colic, n, v, intolerance to fatty foods, flatulence, belching and indigestion; no fever or chills
chronic cholecystitis
management of an episode of biliary colic
analgesics and observations
after cholelithiasis is confirmed, the optimum tx is elective cholecystectomy
oral dissolution therapy
ursodeoxycholic acid taken for 6m-1yr
gallstones that pass through the cystic duct and enter common bile duct
choledocholithiasis
pt presents with jaundice, light colored stools and dark tea colored urine
obstruction of the bile duct
characterized y charcots triad
acute cholangitis
charcots- jaundice, ruq pain, fever
acute suppurative cholangitis
infx accompanying acute cholangitis that progresses to presence of pus in biliary ducts
presents with reynolds pentad
acute suppurative cholangitis
reynolds- ruq pain, jaundice, fever, hypotension, mental confusion
mirizzi’s syndrome
large stone in the gallbladder compresses the common hepatic duct that can lead to obstructive jaundice
lab results for cholangitis
leukocyte count elev
total bili elev
serum ALP/GGT marked elev
AST/ALT mild elevations
management of acute cholangitis
urgent intervention hydrated w IV fluids abx bowel rest blood cx
why are gallstones a common cause of pancreatitis
transient or persistent obstruction of the ampulla of Vater by a large stone or passage of small stones and biliary sludge
management of pts w acute biliary pancreatitis
resuscitation
supportive care
correction of any fluid deficits
when can a laparoscopic cholecystectomy be safely performed with mild/moderate pancreatitis
within the first 48-72hrs of admission
what is performed if someone with gallstone pancreatitis is a poor surgical candidate
endoscopic sphincterotomy
when should a cholecystectomy be performed if pt has severe pancreatitis
delayed until pancreatitis has resolved some weeks or months later but make sure pt is placed on abx
what is a gallstone ileus
mechanical obstruction of the intestine caused by a large gallstone that erodes through the gallbladder into the duodenum; may be assoc w pneumobilia; point of obstruction is often in the distal ileum
what do plain abd xray show for gallstone ileus
findings of small intestinal obstruction and may show air in the biliary tree
what is the preferred dx test for gallstone ileus
ct with oral contrast
tx for gallstone ileus
NG tube for decompression of the obstruction
IV hydration
surgical exploration of the abd and an enterolithotomy
why does gallbladder cancer occur
chronic inflammation MC from cholesterol gallstones
Pt with ruq pain, weight loss, malaise and jaundice
gallbladder cancer
what are the majority of bile duct strictures a result from and why
iatrogenic injury during an operative procedure because of limited blood supply and no redundancy
procedure for open common bile duct exploration
- mobilize the duodenum w Kocher maneuver
- id the duct and make small longitudinal incision in common bile duct
- irrigate lumen w saline using flexible catheters to flush out stones and debris
- inflatable balloon catheters passed prox/dist to extract stones
- small endoscope (choledochoscope)
- all stones and debri removed, duct is irrigated with saline
- T tube placed in lumen of duct and opening of duct is closed around it
when there are multiple stones or if stones left in bile duct what is important to be done during surgery
anastomosis between bile duct and GI tract (choledochoduodenostomy or choledochojejunostomy) so that residual stones may pass easily from duct into intestine
when is the peritoneal drainage catheter removed after T tube has been clamped during bile duct exploration
24-48hr
when are T tubes removed
3-6wks
how are MC bile duct stones removed
ERCP and sphincterotomy
how is a sphincterotomy of the sphincter of Oddi performed
special cautery wire passed through the duodenoscope into the sphincter and then the common duct is cleared using special balloon catheters or wire baskets
41yo F w 18hrs of N, ruq pain and fever. Ate heavy meal night before. Elev WBC, normal bilirubin, slightly elev AST/ALT. Most appropriate study?
US
most likely acute cholecystitis
51yo fever and abd pain, Temp 38.4C. tender w guarding of ruq. WBC 17000. LFs and lipase normal. US ids gallstones, gallbladder wall of 5mm, fluid surround gallbladder. what abx?
Cefoxitin
MC gram neg (e coli and klebsiella) want 2/3 cephalosporin
83yo 2d hx n/v. abd slightly distended and nontender. norm WBC and metabolic alkalosis. abd xray show small bowel obstruction and air in biliary tree. dx?
gallstone ileus
54yo abd pain for 8hrs. mid abd getting worse. elev wbc, amylase 792, normal lfts. US gallstones. Management?
admit, hold intake by mouth, schedule for cholecystectomy before discharge
72yo yellow eyes, dark urine, light stool. diminished appetite. afebrile. jaundiced. nontender smooth globular mass consistent w enlarged gallbladder in ruq. dx?
pancreatic cancer
what regulates bile flow into duodenum
sphincter of Oddi which encircles the common channel
what makes triangle of calot
inferior margin of liver, common hepatic duct, cystic duct
where does most bile acid reabsorption happen
level of terminal ileum
what makes bile more prone to stone formation
greater losses=diminished pool= dec concentration
what is responsible for the green brown color of bile and brown of stool
conjugated bilirubin
direct=water soluble=excreted in urine
indirect=fat soluble=no urine
ways to prevent gallstone formation
avoid obesity, high fiber diet, eat meals at regular intervals, foods w low levels of sat fatty acids
MC type of gallstones
cholesterol, bile acids, lecithin (phospholipid)= cholesterol crystals
where is the source of most stones found in the biliary ducts (choledocholithiasis)
gallbladder
how is biliary colic described
steady visceral dull/aching pain lasting 1-4hrs postprandial lg/fatty meal
what is acute cholecystitis
acute inflammation and infection of the gallbladder
