gallbladder Flashcards
incidence of gallstones
by age 75, 35% of women and 20% of men
30% of people will have symptomatic disease
.what is acute cholecystitis
organisms
gallstone obstruction of the cystic duct
leads to chronic inflammation
e coli most common. klebsiella and gm neg organisms
.colicky epigastic pain or RUQ pain becoming steady and increases in intensity. often occurs after a high fat or large meal
*post prandial abdominal pain, assoc with N/V
acute cholelcystitis symptoms
.+ BOAs sign
acute cholecystitis
referred pain of right shoulder or subscapular area (phrenic nerve irritation)
.labs and imaging to order for acute cholecystitis
*HIDA scan most accurate test (cholecystitis present if no visualization of gallbladder)
u/s initial test of choice
bilirubin levels with increase after 24hrs and leukocytosis common, increased LFTs and alk phos
HIDA scan and ERCP for what
gallstone
HIDA to confirm
ERCP to identify cause, location, and extent of biliary obstruction
what is acute ascending cholangitis
potentially deadly condition of “common bile duct” obstruction combined with ascending infection due to gallstones or malignancy
.charcots triad
RUQ tenderness, jaundice, fever/chills. occurs in 50-70% of acute cholangitis
pt has charcots triad and also altered mental status and hypoTN
sepsis with acute cholangitis
elderly presentation of acute cholangitis
confusion, falls, and incontinence
.incidence of acute ACALCULOUS cholecystitis
describe
r/f
10% of acute cholecystitis
gallballer stasis and ischemia
critically ill pts
.initial management tx for acute cholangitis (3)
antibx (FQ+flagyl, piperacillin/tazobactram, ampicillin/sulbactram, gentamycin + ampicillin, ceftriaxone + flagyl)
followed by CBD decompression and stone extraction once stable ERCP
.what is primary sclerosing cholangitis
r/f
diffuse fibrosis of the intra and extrahepatic biliary ducts
IBS: UC 90%
.80% of primary sclerosing cholangitis is associated with what
inflammatory bowel disease, generally UC
10% of pts with UC will develop PSC
ge.nder and age of primary sclerosing cholangitis
men 20-40
.sx of primary sclerosing cholangitis
jaundice and pruritis most common
hepatomegaly and/or splenomegaly on exam
fatigue, malaise, wt loss
.primary sclerosing cholangitis
accurate test
labs
avoid what
labs: increased alk phos and ggt. ast/alt, bilirubin, igM increased
hallmark: positive P-ANCA
MRCP, ERCP(most accurate test) “beading” mulitiple bile duct strictures
avoid liver bx
.tx for primary sclerosing cholangitis
localized strictures relieved with balloon dilation and stent placement
cholestyramine for pruritis
liver transplant is the only tx with a known survival benefit
complications of gallstones
cholecystitis
pancreatitis
acute cholangitis
tx of acute cholecystitis
non op pt
fluids, antibiotics(ceftrixone + flagyl), then ccy sx
cholecystostomy (perc drainage)
acute cholelcystitis symptoms
radiation
other mild symptoms
colicky epigastic pain or RUQ pain becoming steady and increases in intensity. often occurs after a high fat meal
radiation to rt shoulder or subscapular area
N/V, low fever are common
constipation and mild paralytic ileus may occur
acute cholangitis organisms
other causes
E coli, enterococcus, klebsiella, enterobacter
can lead to sepsis and death
most often caused by choledocholithiasis,
or neoplasms, post op strictures, other causes of obstruction
reynolds pentad
charcot triad
altered mental status
hypotension and shock
all indicate sepsis!! fatal!!
think cholangitis
primary sclerosing cholangitis is strongly associated with what
cholangcarcinoma (10-30% of pts) as well as with an increased risk of pancreatic and colorectal carcinoma
secondary tx for acute cholangitis
[ECRP for drainage and cholecystectomy]
ECRP for drainage, sphincterotomy, stone removal, and stent placement when pt is stable
percutaneous transhepatic biliary drainage or surgical biliary drainage may be required
cholecystectomy should be performed after the acute syndrome is resolved when a stone is present
.5 F’s for gallstones
female
fat
forty
fertile
fair
additional risk factors:
OCP use, rapid wt loss, TPN,
chronic hemolysis(pigment stones in sickle cell disease),
small bowel resection(loss of enterohepatically circulated bile)
gallstones
.acute cholecystitis
symptoms(3) and exam(1)
RUQ pain, N/V, low fever
murphy sign, boa’s sign
.murphy sign
inspiratory arrest with deep palpation of RUQ
acute cholecystitis
risk factors:
native american
DM
pregnancy
crohns
female
obesity
risk factors for cholecystitis
RUQ ultrasonography
increased alk phos and bilirubin
leukocytosis with left shift
ERCP: “beading” mulitiple bile duct strictures
liver bx: “onion skinning” periductal sclerosis
tests for primary sclerosing cholangitis
.why are most gallstones not radiopaque
cholesterol
confusion, falls, and incontinence
elderly presentation of acute cholangitis
.incidence of acute ACALCULOUS cholecystitis
dx test and tx
u/s initial test
contrast enhanced abd CT if u/s is uncertain
HIDA is still uncertain
supportive tx
.acute ascending cholangitis organisms
s/s
e coli most common. klebsiella 2nd.
charcots triad and reynolds pentad
.acute ascending cholangitis
dx labs/imaging
cholestasis
u/s initial
cholangiography via ERCP is gold standard
labs: leukocytosis with poss left shift.
cholestasis: increased alk phos and ggt, increased bilirubin > increased ast/alt
.ERCP can be performed when
once the patient has been afebrile/stable for 48 hours after IV antibx
.what is cholelithiasis
gallstone in biliary tract without inflammation. may get colic abruptly with fatty meal.
.what are black and brown stones
black: hemolysis or alcohol related cirrhosis: increased in asian population, parasitic, or bacterial infections
.what is choledocholithiasis
s/s and tx
gallstone in common bile duct
prolonged biliary colic, jaundice
ercp for dx(after u/s) and tx
.primary biliary cirrhosis/cholangitis disorder of what
age/gender
intrahepatic bile ducts that leads to decreased bile salt excretion, cirrhosis, end stage liver ds
women middle aged
.primary biliary cirrhosis/cholangitis disorder
s/s PE
most asymptomatic, incidental finding of high alk phos
fatigue 1st symptom, pruritis, RUQ discomfort
PE: hepatomegaly, jaundice.
.primary biliary cirrhosis/cholangitis disorder hallmark dx
antimitochondrial antibody.
u/s initial imaging test
bx definitive
