Gallbladder and Biliary Disorders Flashcards
What is cholelithiasis (gallstones)?
Hardened deposits of digestive fluid that form in gallbladder
Are cholelithiasis typically symptomatic?
No, most commonly asymptomatic and do not require treatment
What are the risk factors associated with gallstones?
- Female sex
- Obesity
- Increased age
- Pregnancy/OCPs
- American Indian ethnicity
- Western diet, TPN
- Rapid weight loss
- Family history
What disease process is at high risk for gallstones and should be monitored closely?
Chrohn’s disease, they can’t breakdown bile
What are the three main pathways in which gallstones are formed?
- Cholesterol supersaturation
- Excess bilirubin
- Gallbladder hypo-motility or impaired contractility
What is the most common presenting symptom with gallstones?
Biliary colic (RUQ pain radiating to scapula; most commonly at night. Pain comes and goes)
What are the essentials in diagnosing gallstones?
- Often asymptomatic.
- Classic biliary pain (“episodic gallbladder pain”) characterized by infrequent episodes of steady severe pain in epigastrium or right upper quadrant with radiation to right scapula.
- Gallstones detected on ultrasonography.
What is the treatment of gallstones?
No treatment required for asymptomatic gallstones - diet changes and can refer to general surgeon
What medication can be used for stone dissolution?
Actigall/Ursodiol (not as effective, can be used in small stones)
What is the treatment of choice for symptomatic gallstones?
Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallbladder disease
What are the essentials of diagnosis for acute cholecystitis?
- Steady, severe pain and tenderness in the right hypochondrium or epigastrium.
- Nausea and vomiting.
- Fever and leukocytosis.
Where is the gallstone typically obstructing in acute cholecystitis?
Cystic duct
What are the 4 F’s of acute cholecystitis?
Female, Fat, Forty, and Fertile
How is acute cholecystitis diagnosed?
Transabdominal gallbladder US
What sign will be positive on physical exam in acute cholecystitis?
Murphy’s sign
*RUQ pain/tenderness with deep palpation during inspiration (halts inspiration)
Although not diagnostic, what labs should be run when working up acute cholecystitis and what are some possible findings?
CBC, CMP
Amylase, lipase to r/o pancreatitis
WBC- possible leukocytosis with left shift
LFT’s- normal to slightly elevated
Bilirubin maybe slightly elevated
Although US is the best imaging modality for diagnosing acute cholecystitis what imaging modality is used typically as first line in the ED?
CT
*if CT and US are equivalent should then get HIDA scan
What is acute acalculous cholecystitis?
Cholecystitis without stones (can’t be ignored and typically why HIDA scans are routinely done when suspected)
What complication will result in untreated acute acalculous cholecystitis?
GB gangrene
What are the essentials of diagnosis for choledocholithiasis?
- Often a history of biliary pain, which may be accompanied by jaundice.
- Occasional patients present with painless jaundice.
- Nausea and vomiting.
- Cholangitis should be suspected with fever followed by hypothermia and gram-negative shock, jaundice, and leukocytosis.
- Stones in bile duct most reliably detected by ERCP or EUS.
Where is the stone located in choledocholithiasis?
Common bile duct
What is the presentation of choledocholithiasis?
Pain (colicky, RUQ)
Episodic hx epigastric, RUQ pain
Episodic icterus/jaundice
Clay colored stools, tea colored urine
What will be the color of stool in choledocholithiasis?
Clay colored stools
In choledocolithiasis, increased levels of bilirubin will lead to what color urine?
Tea colored urine
What is Courvoisier’s sign?
Presence of palpable GB (GB dilation due to obstruction of bile duct)
*Seen in choledocholithiasis
Will T. bili be increased in choledocholithiasis?
Increased, > 4 mg/dL
What is the first line imaging in working-up choledocholithiasis?
ABD Ultrasound
What is the treatment for choledocholithiasis?
ERCP (with sphincterotomy to remove stones)
What is the etiology of cholangitis?
Stone in CBD which causes obstruction allowing for bacteria to ascend from duodenum
What is Charcot triad?
Abdominal pain
Jaundice
Fever and chills
*seen in cholangitis
What is Reynolds’ pentad?
Confusion
Hypotension
Abdominal pain
Jaundice
Fever or chills
What is the treatment for cholangitis?
Emergency removal of stones (surgically or endoscopically)
Antibiotics - meropenem, cipro, plus metronidazole
How do you diagnose primary sclerosing cholangitis?
ERCP
What is the treatment for primary sclerosing cholangitis?
Liver transplant
What are the three subtypes of sclerosing cholangitis?
- Classic: affects small and large bile ducts
- Small-duct: affects only small duct
- Autoimmune hepatitis
Ulcerative colitis (IBD) and autoantibodies increase the risk of what disorder?
Primary sclerosing cholangitis (PSC)
*80% of patients have IBD or autoantibodies
PSC is typically asymptomatic, how is PSC typically discovered?
Elevated LFT’s
