Gallbladder Disorders Flashcards
Name at least 4 conditions that would be included in the differential diagnosis in acute cholecystitis.
- IBS (Irritable Bowel Syndrome)
- IBD (Inflam. bowel Dz “Crohn’s”or “ulcerative colitis”)
- Pancreatitis–elevated amylase and lipase usually.
- Acute appendicitis-Elevated levels of ALT
Know the difference between the types of stones in found in cholelithiasis and how etiology will influence treatment.
Cholesterol Stones-(transported within clusters of bile salts called micelles. If there is an imbalance between these bile salts and cholesterol, then the bile fluid turns to sludge. This thickened fluid consists of a mucus gel containing cholesterol and calcium bilirubinate.
If the imbalance worsens, cholesterol crystals form (called supersaturation), which can eventually form gallstones.)
- The liver secretes too much cholesterol into the bile.
- The gallbladder may not be able to empty normally, so that the bile becomes stagnant. (gallbladder hypo-motility)
- The cells lining the gallbladder may not be able to absorb cholesterol and fat from bile efficiently.
- High levels of bilirubin have been observed in patients with gallstones.
Pigment Stones-(Pigment stones are composed of calcium bilirubinate, or calcified bilirubin. Pigment stones can be black or brown.)
Black stones-> Hemolytic anemia or cirrhosis.
Form in the gallbladder and are the more common type. They represent 20% of all gallstones in the US.
Brown stones-(Infxn plays a role in these stones. Bacteria, parasites or other microorganisms may trigger oxidation that cause changes that = BROWN stone formation.)
More common in Asian populations. Stones contain more cholesterol and calcium than black pigment stones & are more likely to occur in the intra and extra-hepatic ducts, NOT GALLBLADDER.
Cholesterol Stones Formation?
- Liver secretes too much cholesterol into bile.
- GB Hypo-motility->GB can’t empty normally=> stagnant.
- Cells lining the GB can’t absorb cholesterol & fat from bile efficiently.
- High levels of bilirubin.
Cholesterol Stones-(transported within clusters of bile salts called micelles. If there is an imbalance between these bile salts and cholesterol, then the bile fluid turns to sludge. This thickened fluid consists of a mucus gel containing cholesterol and calcium bilirubinate.
If the imbalance worsens, cholesterol crystals form (called supersaturation), which can eventually form gallstones.)
Pigment Stones-(Pigment stones are composed of calcium bilirubinate, or calcified bilirubin.
Black stones Formation?
Black stones-> Hemolytic anemia or cirrhosis.
Form in the gallbladder and are the more common type. They represent 20% of all gallstones in the US.
Pigment Stones-(Pigment stones are composed of calcium bilirubinate, or calcified bilirubin.
Brown stones Formation?
Brown stones-(Infxn plays a role in these stones. Bacteria, parasites or other microorganisms may trigger oxidation that cause changes that = BROWN stone formation.)
More common in Asian populations. Stones contain more cholesterol and calcium than black pigment stones & are more likely to occur in the intra and extra-hepatic ducts, NOT GALLBLADDER.
What are the best methods of imaging for cholelithiasis?
*Endoscopic Retrograde Cholangiopancreatography (ERCP)=>gold standard for detecting common bile duct stones, particularly because they can be removed during the procedure. However, it is invasive and carries a risk for complications.
*Ultrasound - most frequently used, method of choice for detecting acute cholecystitis.
While an accuracy of 90% to 95%, does not appear to be very useful for identifying cholecystitis in symptomatic patients who do not have gallstones.
Also not as useful for common bile duct stones and cannot image the cystic duct.
- X-Rays- may detect calcified gallstones and gas.
- Cholescintigraphy (Gallbladder Radionuclide Scan, HIDA).Nuclear imaging technique, is more sensitive than ultrasound for diagnosing acute cholecystitis.
- Computed Tomography. valuable additional imaging technique if complicating features, such as perforation, common duct stones, or other problems such as cancer in the pancreas or gallbladder.
- Magnetic Resonance Imaging (MRI). very useful for detecting common bile duct stones
- Virtual Endoscopy. Virtual endoscopy is an investigative technique that uses data from CT and MRI scans to generate a three-dimensional internal view of various body structures. The images resemble those used in endoscopy but the procedure is noninvasive. At this time it is still experimental.
Which hydrotherapies are best for cholelithiasis, biliary dyskinesia, and cholecystitis?
Biliary Dyskinesia->Castor oil packs (Slide #12)
(ACUTE)-Castor oil packs Chaparral infused castor oil (Yarnell) More effective than castor oil in acute GB colic No heat with acute sxs 30 min. TID
(CHRONIC)-Vinegar packs
Alternating hot (vinegar) and cold packs
Non-acute only
What dietary/lifestyle changes are appropriate for cholelithiasis and biliary dyskinesia?
- Avoidance of saturated fat and high glycemic index foods
- Food Allergy/Intolerance avoidance
- Elimination/Challenge diet
- Tobacco cessation
- Exercise (30 mins. 5x/wk)
- Liver cleansing foods (beets, radishes, burdock root)
- High water soluble foods (flax seed, guar gum, oat bran, etc.
Know the role of food allergies, and which ones are commonly seen in Cholelithiasis, biliary dyskinesia, and cholecystitis.
All 69 patients were free from all gallbladder symptoms while they were on the basic elimination diet. Gallbladder symptoms recurred in the following % of patients when each of the following foods were added back into the diet:
Food Patients whose symptoms returned
# %
Egg 64 92.8%
Pork 44 63.8%
Onion 36 52.0%
Fowl 24 34.8%
Milk 17 24.6%
Coffee 15 21.7%
Orange 13 18.8%
Corn 10 14.5%
Beans 10 14.5%
Nuts 10 14.5%
Apple 6 8.7%
Tomato 6 6.0%
Peas 4 5.8%
Cabbage 4 5.8%
Spices 3 4.3%
Peanut 3 4.3%
Fish 2 2.9%
Rye 1 1.4%
Medications 14 20.3%
Other 29 42.0%
alcohol, hot sauces, spicy foods, fried foods, fatty foods, rich foods, salty foods, heavy protein foods, cow’s milk and other dairy products, white bread, refined foods, processed foods, sugar and sweets; catarrh-forming foods: meat, ice cream, shellfish
What are the primary etiologies for cholelithaisis?
The formation of gallstones is a complex process that starts with bile, composed mostly of water, bile salts, lecithin and cholesterol.
- Hormone Replacement Therapy (estrogenic effects)
- Oral birth control pills (mild risk)
- Thiazide diuretics (moderate risk)
- Fibric acid derivatives (Tricor)
- Ceftriaxone ( biliary motility)
- Somatostatin and analogs
- Total parenteral nutrition
- Tamoxifen
- Bariatric surgery (not lap band)
PREDISPOSING FACTORS: FAIR, FAT, FORTY, FEMALE & FERTILE (Women are twice as likely as men to develop them.)
More prevalent in women and Hispanics and latinos with high cholesterol diets.
High fiber diet decreases gall stone formation, ↓transit time so less time for gut bacteria to form lithogenic bile acids.
Why isn’t lithotripsy used more often as a therapy?
Lithotripsy caused one or more adverse effects in 50% of the patients. Minor side effects during the procedure were right upper quadrant dis- comfort(7%) responding to a slight reduction of the intensity, vagal reaction (1%), and skin petechiae(5%).In one patient an acute abdominal pain syndrome caused by a hematoma in the gallbladder wall necessitated the interruption of the tx.
In the days or weeks after the Lithotripsy 36%
of the patients had attacks of biliary pain.In the majority, pain responded well to minor analgesics. Laboratory and clinical signs of mild pancreatitis occurred in two patients(03%). Five per cent complained of diarrhoea that resolved after a slight reduction of the bile acid medication.
Major side effects resulting in interruption of the treatment were uncontrolled biliary colics in 13 patients, cholecystitis in seven patients and acute pancreatitis in two patients.Twenty five patients were lost to follow up.
Understand the role of exercise (or lack thereof) in gallbladder conditions.
Exercise:
Essential aspect of lifestyle change.
*Study: exercising 30 minutes 5x/week eliminated 34% of cases of symptomatic gallstones.
- Obvious benefit in reducing obesity.
- Exercise also helps reduce cholesterol levels in the biliary tract.
What are the appropriate herbal therapies for cholelithiasis, biliary dyskinesia, and cholecystitis, how do they differ?
Acute Cholecystitis Tincture (Yarnell)
Herb Percent
Echinacea angustifolia root 20-30%
Dioscorea villosa root (wild yam) 15-25%
Ammi visnaga seed (khella) 15-20%
Ceanothus greggii root (redroot) 10-20%
Baptisia tinctoria root (wild indigo) 10-15%
Fumaria off. Herb (fumitory) 10-15%
Zingiber off. rhizome (ginger) 5-10%
Acute homeopathy questions may be present, but only in instances where remedy examples are given in the notes.
Carduus marianum: pain on left side below rib cage; vertigo with backward falling; constipation with hard, knotty evacuation expelled with great difficulty
Chelidonium: constant pain in right scapula; nausea with vomiting; pain temporarily > by eating, pressure, heat; walking
Podophyllum: pain in epigastrium with distention and sense of vacuum therein; great thirst for water; diarrhea painful, green, watery, too profuse, fetid, expelled like water jet; alternately constipated
