Gastro - Online MedEd - gallbladder

Question 1

Cholelithiasis - what is it?

Answer 1

Bunch of stones in gallbladder
3 types of gallstones
Won’t know which type until take out gall bladder

Question 2

Gallstones are what types

Answer 2

Cholesterol - green, from Five F’s: fat, female, forty, fertile, Native American
Pigmented stones - black, from hemolysis
Mixed of both - is most common

Question 3

Cholelithiasis - presentation

Answer 3

Colicky, RUQ pain radiate to shoulder
Worse with fatty foods
Fatty foods cause more contraction of gall bladder

Question 4

Cholelithiasis - dx?

Answer 4

US –> see gallstones

US is first diagnostic imaging for all gallstone disease!

Question 5

Treatment - cholelithiasis

Answer 5

Elective cholecystectomy (not emergent)
Not surgical candidate: ursodeoxycholic acid (i.e. very old patient)
But generally curative

Question 6

Gall stone pops out and ends up in duct gets…

Answer 6

Cholecystitis =
Obstruction of cystic duct –> gall bladder gets big inflamed and angry
Gallstone stuck in cystic duct

Question 7

US of cholecystitis

Answer 7

This is first set of imaging
Pericholecystic fluid
Thickened gallbladder wall
Gallstones - others in the gall bladder, but rarely see obstructing stone

Question 8

Cholecystitis - presentation

Answer 8

Constant RUQ pain
Positive Murphy’s sign - jab thumb into gallbladder with inspiration
Due to inflammation - mild fever and mild leukocytosis

Question 9

Dx of cholecystitis

Answer 9

1) US - rarely see obstructing stone
2) HIDA scan - get radio tracer –> fill gall bladder into biliary tree = normal; if there is cholecystitis –> biliary tree will fill, but gallbladder won’t
HIDA scan positive = no radioactive tracer in gall bladder!

Question 10

Treatment of cholecystitis

Answer 10

NPO
IVF
IV antibiotics
-Start with above, but do surgery
Cholecystectomy - urgent, within 72-96 hours (not emergent)
-If not a surgical candidate, can do a cholecystotomy –> put in a tube to drain away the inflammation

Question 11

Choledocholithiasis - what is it?

Answer 11

Stone comes out of cystic duct –> common bile duct

• If down to ampulla of vater –> can get inflammation of liver (hepatitis, elevated bilirubin), pancreas (gall stone pancreatitis, elevated amylase)
• Will certainly have obstructive jaundice

Question 12

Painful jaundice is…

Answer 12

Choledocholithiasis

Stone stuck in common bile duct cause painful obstructive jaundice

Question 13

Presentation - choledocholithiasis

Answer 13

Murphy’s

Inflammation - mild fever/leukocytosis

Question 14

Dx choledocholithiasis

Answer 14

US - may see dilated ducts/obstruction, if don’t see dilated ducts then there is unlikely to be a stone in the common bile duct
*If think there is choledocholithiasis because there is painful jaundice (direct hyperbilirubinemia) BUT US is negative –> get the MRCP (do not use HIDA)

Question 15

When to use MRCP?

Answer 15

When there is painful jaundice (indicating choledocholithiasis) but there is negative US

Question 16

Treatment of choledocholithiasis

Answer 16

ERCP urgent!
NPO, give fluids and IV antibiotics initially with goal to ERCP
Then do cholecystectomy (elective)
-Why give IV antibiotics –> in case it becomes cholangitis

In reality…

1) Gen Surg: cholecystectomy, then intraoperative cholangiogram to remove the stones from the back
2) Gastro: scope down esophagus –> ampulla of vater/ERCP –> sphincterotomy –> pull out stones –> then surgeon removes gall bladder in the future

Question 17

Sometimes… can dx choledocholithiasis… but next day…

Answer 17

Patient is better
Enzymes have removed etc.
What has happened? stone moved out of the way, may not need to do ERCP
Then enzymes go up again –> means stone is moving up and down! Ball-valve effect
-Still need ERCP!

Question 18

Cholangitis - is the most serious of all gall bladder diseases!
What is it?

Answer 18

Dilated ducts!
Gallstones in common bile duct + obstructing stone = like choledocholithiasis
Now there is Stagnant fluid –> nidus of infection –> bacteria grow and cause ascending infection up the tree!

Question 19

What type of infection of cholangitis?

Answer 19

Gram negative rods

Anaerobes

Question 20

Presentation of cholangitis

Answer 20

RUQ abdominal pain
Painful jaundice
Fever 
= Charcot's triad for cholangitis
Might also have hypotension and altered mental status
= Reynaud's pentad

Question 21

Dx of cholangitis

Answer 21

RUQ US - obstruction, dilated ducts, but won’t see obstructed stone
Don’t do MRCP, HIDA

Question 22

Treatment of cholangitis

Answer 22

If have infection, will need surgery right away!
No amount of antibiotics will clear the infection
Therapeutic and diagnostic step: ERCP emergent!!
Then do cholecystectomy (usually urgent, sometime elective)
Need initial resuscitation: IVF, NPO, IV antibiotics while waiting for surgery
In real life will be emergency ERCP

Question 23

Which IV Antibiotics for cholangitis?

Answer 23

GNR and anaerobes
Same bugs of GI tract
Regimens:
1) Ciprofloxacin and Metronidazole
2) Ampicillin, gentamycin, metronidazole
-Pip/Tazo - do not pick, it does cover this, but also covers Gram positive (over-covering for Strep and Pseudomonas), not antibiotics stewardship - easily done in hospital