Gallstones, Gallbladder pathology, gallbladder polyps and cancer Flashcards
gallstones on imaging without symptoms
no treatment
gallstones on imaging w/ typical biliary colic sx
acute pain management get a cholecystectomy possible ursodeoxycholic acid in poor surgical candidates or refusing surgery
gallstones with atypical symptoms
evaluate for other causes trial ursodoxycholic or cholecystectomy in pts who’s sx improve
what to do for typical biliary colic symptoms w/o gallstones on imaging
get a cholecystokinin stimulated cholescintigraphy (HIDA) to evaluate functional gallbladder disorder cholecystectomy in pts with low gallbladder ejection
RF for gallstones
obesity, female, age>40, hemolytic anemias, pregnancy, certain medications (OCP) and hypertriglyceridemia
asymptomatic gallstones are
no intervention low risk for furture complications.
biliary colic is
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.
presentation of acute cholecystitis
prolonged RUQ pain,
radiation to back and right shoulder,
fevers,
jaundice
elevated hepatobiliary markers.
Algorithm for elevated alkaline phosphatase
Empiric antibiotics for acute cholecystitis
zosyn (piperacillin-tazobactam monotherapy)
or
ceftriaxone + metronidazole
or
carbapenem for monotherapy
or
fluoroquinolone + metronidazole
management of acute cystitis
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.
when to get ERCP?
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.
what do for people with mild to moderate gallstone symptoms but are not surgery candidates?
can consider dissolution therapy of gallstones with ursodeoxycholic acid
but not for acute cholecystitis.
when do we do cholecystectomy in asymptomatic pts who have gallstones seen?
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.
what is acalculous cholecystitis?
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.
Treatment of acalculous cholecystitis?
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.
Risk factors for acalculous cholecystitis?
see this in aortic surgery, cardiac surgery, sepsis, burns and vasculitis pts.
gall bladder polyp <5 mm
repeat ultrasoiund in 12 months and cholecystectomy if increases in size
gallbladder polyp is 6-9 mm in size
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.
Gallstone cancer risk factors
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
gallstone polyp >1 cm
cholecystectomy
If pt has these features, what to do next?
gallbladder polyp (any size) + gallstones, biliary colic
primary sclerosing cholangitis + gallstone polyp >8 mm
prophylactic cholecystectomy
gallbladder serves as a reservoir for this bacteria
salmonella typhi - these pts are also at higher risk for gallbladder cancer
what is cholangiocarcinoma
what are risk factors for this?
malignancy of the intrahepatic biliary ducts.
classified as three types:
- intrahepatic = seen in smaller bile ducts within the liver parenchyma
- 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
Presentation of Gallbladder cancer and when to suspect:
presents as RUQ pain, nausea, vomiting, weight loss and jaundice. See biliary colic in early cancer
CT and MRI will show enhancing gallbladder mass
Diagnosis of gallbladder cancer?
Treatment of gallbladder cancer?
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.
diagnosis of cholangiocarcinoma?
Depends on the type and location
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.
metastatic cholangiocarcinoma chemotherapy is with
gemcitabine and cisplatin
Most common cause of pancreatitis?
gallstones
