Gallstones, Gallbladder pathology, gallbladder polyps and cancer

Question 1

gallstones on imaging without symptoms

Answer 1

no treatment

Question 2

gallstones on imaging w/ typical biliary colic sx

Answer 2

acute pain management get a cholecystectomy possible ursodeoxycholic acid in poor surgical candidates or refusing surgery

Question 3

gallstones with atypical symptoms

Answer 3

evaluate for other causes trial ursodoxycholic or cholecystectomy in pts who’s sx improve

Question 4

what to do for typical biliary colic symptoms w/o gallstones on imaging

Answer 4

get a cholecystokinin stimulated cholescintigraphy (HIDA) to evaluate functional gallbladder disorder cholecystectomy in pts with low gallbladder ejection

Question 5

RF for gallstones

Answer 5

obesity, female, age>40, hemolytic anemias, pregnancy, certain medications (OCP) and hypertriglyceridemia

Question 6

asymptomatic gallstones are

Answer 6

no intervention low risk for furture complications.

Question 7

biliary colic is

Answer 7

episode pain in RUQ, radiation to back or right shoulder symptoms with fatty foods (due to gall bladder contraction)

can see n/v/diaphoresis and this lasts for 2-6 hrs

pts with unrelenting right upper quadrant or epigastric pain do not have biliary colic generally.

Question 8

presentation of acute cholecystitis

Answer 8

prolonged RUQ pain,

radiation to back and right shoulder,

fevers,

jaundice

elevated hepatobiliary markers.

Question 9

Algorithm for elevated alkaline phosphatase

Answer 9

Question 10

Empiric antibiotics for acute cholecystitis

Answer 10

zosyn (piperacillin-tazobactam monotherapy)

or

ceftriaxone + metronidazole

or

carbapenem for monotherapy

or

fluoroquinolone + metronidazole

Question 11

management of acute cystitis

Answer 11

based on clinical status and risk for surgery

Low risk, hemodynamically stable pts: undergo early laparoscopic cholecystectomy - lower risk of morbidity and mortality

High risk for surgery (elderly pt with comorbidites) - first would try conservative but if becomes hemodynamically unstable or is hemodynamically unstable to start need to get percutaneous cholecystostomy tube.

Question 12

when to get ERCP?

Answer 12

ERCP is only in people who have choledocholithiasis complicated by biliary pancreatitis or cholangitis

Would see enlarged bile duct, alkaline phosphatase and elevated bilirubin levels and lipase levels.

Question 13

what do for people with mild to moderate gallstone symptoms but are not surgery candidates?

Answer 13

can consider dissolution therapy of gallstones with ursodeoxycholic acid

but not for acute cholecystitis.

Question 14

when do we do cholecystectomy in asymptomatic pts who have gallstones seen?

Answer 14

remove gallbladder in asymptomatic pts when there is high risk for gallbladder cancer:

• gallstones >3 cm in size,
• porcelain gallbladder (intramural calficication of the wall)
• gallbladder adenomas or polyps >1 cm in size
• anomaly in pancreatic ductal drainage
• primary sclerosing cholangitis + gallstone polyp >8 mm
• gallstone polyp (any size) + gallstones or biliary colic.

Question 15

what is acalculous cholecystitis?

Answer 15

this is where there is gallbladder ischemia that can be complicated by bacterial infection. seen in critically ill pts.

mortality if untreated is up to 75%

Presentation differs based on if pt is ventilated or awake.

Awake non sedated - Presents with pain and see cholecystitis related to gallbladder

Mechanically ventilated pts- presentation is leukocytosis, jaundice and sepsis

U/S abdomen- shows gallbladder wall thickening and pericholecystic fluid and gallbladder distension and may see gallbladder wall pneumatosis in absence of calculi.

Question 16

Treatment of acalculous cholecystitis?

Answer 16

Treatment is with IV antibiotics to cover enteric bacteria and cholecystectomy

cholecystostomy tube may be needed if pt is unstable or poor candidate for surgery.

Question 17

Risk factors for acalculous cholecystitis?

Answer 17

see this in aortic surgery, cardiac surgery, sepsis, burns and vasculitis pts.

Question 18

gall bladder polyp <5 mm

Answer 18

repeat ultrasoiund in 12 months and cholecystectomy if increases in size

Question 19

gallbladder polyp is 6-9 mm in size

Answer 19

repeat U/S abdomen in 6 months then yearly

cholecystectomy if increases in size.

Rationale: gallbladder polyps associated with gallbladder stones or primary sclerosing cholangitis are also more likely to be neoplastic and risk for cancer.

Question 20

Gallstone cancer risk factors

Answer 20

most common biliary cancer,

Risk factors:

female sex,

ethnicity or race (american Indian, Alaskan native, black), cholelithiasis,

gallbladder poylps,

porcelain gallbladder,

anomalous pancreaticobiliary junction and obesity

chronic salmonella typhi pts

Question 21

gallstone polyp >1 cm

Answer 21

cholecystectomy

Question 22

If pt has these features, what to do next?

gallbladder polyp (any size) + gallstones, biliary colic

primary sclerosing cholangitis + gallstone polyp >8 mm

Answer 22

prophylactic cholecystectomy

Question 23

gallbladder serves as a reservoir for this bacteria

Answer 23

salmonella typhi - these pts are also at higher risk for gallbladder cancer

Question 24

what is cholangiocarcinoma

what are risk factors for this?

Answer 24

malignancy of the intrahepatic biliary ducts.

classified as three types:

1. intrahepatic = seen in smaller bile ducts within the liver parenchyma
2. hilar= from confluence of right and left hepatic duct

3 = distal arising distal to cystic duct entrance

Risk factors: primary sclerosing cholangitis, choledochal cysts, liver flukes, exposure to thorium dioxide and hepatolithiasis

Question 25

Presentation of Gallbladder cancer and when to suspect:

Answer 25

presents as RUQ pain, nausea, vomiting, weight loss and jaundice. See biliary colic in early cancer

CT and MRI will show enhancing gallbladder mass

Question 26

Diagnosis of gallbladder cancer?

Treatment of gallbladder cancer?

Answer 26

Early gallbladder cancer is diagnosed incidentally at the time of cholecystectomy for biliary colic.

Stage T1a - see invasion into lamina propria do not need further treatment. Advanced lesions need extended cholecystectomy

Treatment of choice is = surgery -

unresectable disease is chemotherapy with or without radiation and palliative care.

Question 27

diagnosis of cholangiocarcinoma?

Depends on the type and location

Answer 27

intrahepatic cholangiocarcinoma - diagnosed via the CT or MRI imaging and with biopsy

elevated Ca 19-9 is suggestive but not sufficient

Therapy is resection, locoregional, or systemic chemotherapy.

hiliar cholangiocarcinoma - diagnosis is challenging and needs combo of MRCP and ERCP with bile duct brushings obtained for cytological exam and fluorescence in situ hybridization testing. Can see an elevated Ca 19-9 but need _ERCP every 2-3 month_s to make diagnosis

therapy: resection; may need a ERCP and stent placemnt if there’s obstructive jaundice.

Can get liver transplantation for hiliar cholangiocarcinoma if there was no transluminal biopsy of hiliar cholangiocarcinoma as there is a risk for seeding. Tumor must be <3 cm and no extrahepatic spread. Then needs neoadjuvant chemoradiation

distal cholangiocarcinoma - seen with CT or MRI and needs biopsy. Treatment is whipple procedure.

Question 28

metastatic cholangiocarcinoma chemotherapy is with

Answer 28

gemcitabine and cisplatin

Question 29

Most common cause of pancreatitis?

Answer 29

gallstones