Gastro - Online MedEd - gallbladder Flashcards
Cholelithiasis - what is it?
Bunch of stones in gallbladder
3 types of gallstones
Won’t know which type until take out gall bladder
Gallstones are what types
Cholesterol - green, from Five F’s: fat, female, forty, fertile, Native American
Pigmented stones - black, from hemolysis
Mixed of both - is most common
Cholelithiasis - presentation
Colicky, RUQ pain radiate to shoulder
Worse with fatty foods
Fatty foods cause more contraction of gall bladder
Cholelithiasis - dx?
US –> see gallstones
US is first diagnostic imaging for all gallstone disease!
Treatment - cholelithiasis
Elective cholecystectomy (not emergent)
Not surgical candidate: ursodeoxycholic acid (i.e. very old patient)
But generally curative
Gall stone pops out and ends up in duct gets…
Cholecystitis =
Obstruction of cystic duct –> gall bladder gets big inflamed and angry
Gallstone stuck in cystic duct
US of cholecystitis
This is first set of imaging
Pericholecystic fluid
Thickened gallbladder wall
Gallstones - others in the gall bladder, but rarely see obstructing stone
Cholecystitis - presentation
Constant RUQ pain
Positive Murphy’s sign - jab thumb into gallbladder with inspiration
Due to inflammation - mild fever and mild leukocytosis
Dx of cholecystitis
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!
Treatment of cholecystitis
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
Choledocholithiasis - what is it?
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
Painful jaundice is…
Choledocholithiasis
Stone stuck in common bile duct cause painful obstructive jaundice
Presentation - choledocholithiasis
Murphy’s
Inflammation - mild fever/leukocytosis
Dx choledocholithiasis
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)
When to use MRCP?
When there is painful jaundice (indicating choledocholithiasis) but there is negative US
Treatment of choledocholithiasis
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
Sometimes… can dx choledocholithiasis… but next day…
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!
Cholangitis - is the most serious of all gall bladder diseases!
What is it?
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!
What type of infection of cholangitis?
Gram negative rods
Anaerobes
Presentation of cholangitis
RUQ abdominal pain Painful jaundice Fever = Charcot's triad for cholangitis Might also have hypotension and altered mental status = Reynaud's pentad
Dx of cholangitis
RUQ US - obstruction, dilated ducts, but won’t see obstructed stone
Don’t do MRCP, HIDA
Treatment of cholangitis
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
Which IV Antibiotics for cholangitis?
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
