Gen Surg: Obstructive Jaundice and Biliary Calculus Disease Flashcards
Common causes of jaundice
Pre-hepatic: hemolysis, hematoma, biloma reabsorption.
Hepatic: enzyme deficiency, infection, trauma, neoplasm, drugs, autoimmune, vascular, metastases.
Post-hepatic (obstructive): anatomic (proximal vs distal biliary tree).
Stricture (e.g. from cholangiocarcinoma, cholangitis, trauma, PSC, ischemia/inflammation, iatrogenic).
Luminal causes (e.g. choledocholithiasis, parasites, foreign body, clot).
External compression (Mirizzi’s syndrome, pancreatitis, neoplasm of pancreas, dueodenum or ampulla of vater)
Presentation of obstructive jaundice
Painful RUQ. Cola-colored urine, pale stools. N/V, B symptoms. PMHx of DM, IVDU, drugs. CT imaging: look for intra- vs extra-hepatic duct dilatation.
Etiology/presentation of biliary calculus disease: cholelithiasis, biliary colic, cholecystitis, choledocholithiasis, cholangitis & gallstone pancreatitis.
Asymptomatic cholelithiasis: no surgery needed. RF for stones… cholesterol stones -> age, sex, prgnancy, obesity, hereditary. Brown pigment -> pathologic biliary stasis, black pigment -> excessive heme turnover.
Biliary colic: Stone obstructing gallbladder outflow but with quick resolution. RUQ/epigastric pain starting several hours after a large, fatty meal. Lasts for hours but resolves. No peritonitis/fever/jaundice –> no inflammation! Investigate with US (look for cholelithiasis). Tx with analgesia, outpt surgery referral for elective cholecystectomy.
Acute cholecystitis: inflammation due to stone in cystic duct. RUQ/epigastric severe persistent pain with guarding. Inflammation –> Murphy’s sign, rebound tenderness +/- fever. Elevated WBC.
Choledocholithiasis: stones in CBD. symptoms similar to acute cholecystitis PLUS jaundice. On US, ductal dilatation + stone in CBD. Complications: cholangitis, gallstone pancreatitis, obstructive jaundice.
Cholangitis: infection due to CBD obstruction. Charcot’s triad (RUQ pain, jaundice, fever) vs Reynold’s pentad (triad + shock + decreased LOC). Tx w/ resuscitation IVF + abx + urgent ERCP to decompress biliary tree.
Gallstone pancreatitis: stone passes or obstructs sphincter of oddi.
Dx + Mgmt acute cholecystitis
Investigations: elevated WBC, May see elevated ALP, bili, GGT.
US: look for stone in neck of gallbladder, sonographic murphy, wall thickening >4 mm, peri-cholecystic fluid, may eventually necrose.
NPO, IVF, abx to cover gram negatives.
Lap chole.
If poor surgical candidate: percutaneous cholecystostomy darin
Dx + Mgmt choledocholithiasis
US: stone in CBD to dx.
ERCP: diagnostic and therapeutic.
MRCP: only diagnostic.
Endoscopic US: less invasive than ERCP but non-therapeutic. Allows sampling of LN, assessment of stomach, pancreas, liver, biliary tree.
Tx: remove stone. ERCP (endoscopic retrograde cholangiopancreatography) to image, remove stone, widen sphincter and place stent. Alternatively, can decompress proximally with percutaneous transhepatic biliary drain.
Gallstone pancreatitis: SS, investigations, mgmt
Severe epigrastric/RUQ pain radiating to back with guarding and rebound tenderness. No EtOH Hx. Hx biliary colic.
Labs: elevated WBC, lipase, GGT, ALP.
US: biliary stones
CT: peripancreatic edema and fat stranding.
Mgmt:
ABCs, IVF, abx
ERCP for stones in biliary tree.
Cholecystectomy.
Complications of stones
Mirizzi’s syndrome: impacted gallstone in cystic duct causes inflammation into bile duct. Get extraluminal obstruction of biliary tree from distention of cystic duct. Must rule out cholangiocarcinoma.
Gallstone ileus: mechanical obstruction thus not true ileus. Stone impacted in small bowel causes distal obstruction. Chronic inflammation –> cholecysto-enteric fistula. Stone moves through small bowel then lodges at narrowest area, usually terminal ileum. More common in elderly, frail women.
Presentation and workup of suspected pancreatic malignancy
Painless jaundice.
Courvoisier’s sign: non-tender, palpable RUQ mass in patient with painless jaundice.
Dx w/ CT.
