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MBBS IV - Junior Clerkship WCS > JC63C (Surgery) - Cholangitis and Cholecystitis > Flashcards

JC63C (Surgery) - Cholangitis and Cholecystitis Flashcards

1
Q

Major etiologies of acute cholecystitis

A

Acute cholecystitis
• Calculous cholecystitis (90 – 95%): Obstruction of the cystic duct by an impacted gallstones
• Acalculous cholecystitis
• Tumour obstructing the cystic duct (<1%)

Acute cholecystitis:

Bacteria in bile: gram negative rods, enterococci

Bile duct obstruction: Stones, tumors, benign strictures

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2
Q

Pathogenesis of chronic cholecystitis /

A

Associated with presence of gallstones: mechanical irritation or recurrent attacks of acute cholecystitis leading to fibrosis and thickening of gallbladder

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3
Q

Acalculous cholecystitis

  • Demographic
  • Associated diseases
  • Pathogenesis
  • S/S
  • Dx and Tx
A

Demographic: patients with other acute systemic diseases or critically-ill patients

Associated diseases: TPN, extensive burns, sepsis, major operations, multiple trauma or prolonged illness with multi-organ dysfunction are at risk

Pathogenesis: NOT associated with presence of gallstone, gallbladder distension with bile stasis and ischemia

S/S: fever, RUQ pain and leukocytosis

Dx and Tx:

  • USG and HIDA scan
  • Urgent systemic antibiotics + percutaneous USG/CT-guide cholecystostomy or interval cholecystectomy
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4
Q

Pathogenesis of cholecystitis /

A

3 steps:

Cystic duct obstruction >>> distension, inflammation and edema of gallbladder wall

Bile stasis >>> chemical irritant such as lysolecithin (mucosal toxin in bile) cause inflammation in gallbladder

Infection of biliary system >>> Secondary bacterial contamination/ Infected bile by E. coli, Enterobacter, Klebsiella and Enterococcus sp.

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5
Q

Abdominal pain characteristics of acute cholecystitis

(SOCRATES)

A

Abdominal pain
• Site: RUQ or epigastrium
• Onset: Sudden onset
• Character: Steady
• Radiation: Right shoulder (interscapular area) (Boas sign) or back
• Associated symptoms: Fever, anorexia, nausea and vomiting
• Time course: Prolonged for > 4 – 6 hours
• Exacerbating factors: Movement
• Reliving factors: Rest (Reluctant to move)
• Severity: Severe

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6
Q

Ddx acute cholecystitis

A

• Biliary colic: gallbladder contraction against gallbladder obstruction after fatty meal

  • Peptic ulcer disease (PUD)
  • Acute pancreatitis
  • Acute appendicitis
  • Acute hepatitis
  • Irritable bowel syndrome
  • Sphincter of Oddi dysfunction
  • Pneumonia
  • Pleuritis
  • Myocardial infarction (MI)
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7
Q

Complications of cholecystitis

A

Gallbladder:

  • Mucocele, Empyema, Rupture

Acute cholangitis

Acute pancreatitis

Cholecysteoduodeno-fistula

Liver abscess

…etc

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8
Q

Acute cholecystitis

Diagnostic criteria /

A

Diagnostic criteria (Tokyo criteria 2013)

Diagnostic components
• A: Local signs of inflammation
o Murphy’s sign
o RUQ mass/ pain/ tenderness

• B: Systemic signs of inflammation
o Fever
o Leukocytosis
o Elevated CRP level

• C: Imaging findings
o Imaging findings characteristic of acute cholecystitis

Definite diagnosis = One time in A + One item in B + One time in C

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9
Q

P/E signs of acute cholecystitis

A

General examination
• Ill-appearance lying still on bed - peritoneal inflammation, Jaundice, Fever, Tachycardia

Abdominal exam:

Localized RUQ tenderness
• Guarding
• Rigidity
• Murphy’s sign* Gallbladder pain with breathing > grasp for air***

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10
Q

First-line investigations for acute cholecystitis

A

Blood:

  • CBC with differentials
  • LFT
    • Liver chemistry is usually NORMAL +/- mild elevation of bilirubin, ALP, transaminases and amylase

Radiological:

  • Abdominal USG: presence of gallstones + Gallbladder distention, edema, wall thickening, Sonographic Murphy’s sign
  • Radionucleotide Cholescintigraphy (HIDA scan): Tc-99m HIDA for visualization of biliary system, show failure of gallbladder to fill with dye
  • MRCP: intra-hepatic and extrahepatic ducts
  • CT abdomen: detect complications
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11
Q

First-line treatment for acute cholecystitis

A

1. General
 Nil by mouth (NPO)
 vitals
 Blood test including cross-match

  1. Medical treatment
    IV fluids
     Analgesics: NSAIDs
    IV Antibiotics: vs secondary infection and complications

Empirical antibiotics should cover for gram -ve aerobes and anaerobes: Cefuroxime, Metronidazole, Piperacillin + Tazobactam/ Tazocin

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12
Q

Surgical treatment options for acute cholecystitis **

A

Surgical resection:

  • Open/ Laparoscopic cholecystectomy
  • Early laparoscopic cholecystectomy (48-72h)
  • Delayed/ interval laparoscopic cholecystectomy (6-10weeks)

Gallbladder drainage:

  • Percutaneous cholecystostomy
  • Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD)
  • Endoscopic transpapillary drainage by ERCP (ETGBD)
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13
Q

Compare open vs Laparoscopic cholecystectomy

Pros and cons

A

Open:

  • Lower complications
  • Lower conversion rate
  • More pain, Longer hospital stay

Laparoscopic:

  • Less pain
  • Shorter hospital stay
  • Faster recovery
  • Better cosmesis
  • CONS: Higher conversion rate, Higher complication rate, More technically demanding
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14
Q

Compare early vs Delayed/ interval laparoscopic cholecystectomy

A

Early cholecystectomy should always be recommended unless contraindicated

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15
Q

Gallbladder drainage for acute cholecystitis **

  • Indications
  • Methods
A
  • *Indication**
  • *o Severe acute cholecystitis (Grade III)/ difficult cholecystectomy**
  • *o Hemodynamically unstable**
  • *o Failure of medical (antibiotic) therapy**
  • *o High surgical risk**

Methods:

Percutaneous cholecystectomy **

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD)

Endoscopic transpapillary drainage by ERCP (ETGBD)

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16
Q

Acute cholangitis /

Pathogenesis

A

Obstruction with bacterial overgrowth = Acute cholangitis (infection of bile duct)

Biliary obstruction and stasis predisposes to bacterial infection of biliary tree
o Ascending infection from duodenum
o Hematogenous spread from portal veins

Disrupted normal barrier mechanism
• Normal barrier is disrupted after endoscopic sphincterotomy, biliary stent insertion and choledochal surgery
• Incomplete biliary drainage or biliary stent blockage or Presence of foreign body serves as a nidus for bacterial colonization

17
Q

Acute cholangitis

Etiologies/ Causes

A
  • * Choledocholithiasis (most common)**
  • * Benign or malignant strictures (MBO)** of bile ducts or at biliary-enteric anastomosis
  • * Indwelling stents (stent occlusion)** or instrumentation of ducts
  • * Tumours**
  • * Parasitic infection**
18
Q

S/S of acute cholangitis

A
  • *Charcot’s triad (present in 2/3 of patients)**
  • *• Fever**
  • *• Abdominal pain**
  • *• Jaundice**

Reynolds pentad (present in < 10% of patients)
• Fever
• Abdominal pain
• Jaundice
• Hypotension (septic shock)
• Altered mental status (Confusion)

19
Q

Ddx acute cholangitis

A

Differential diagnosis of fever and abdominal pain
• Recurrent pyogenic cholangitis
• Acute cholecystitis
• Acute pancreatitis
• Acute appendicitis
• Liver abscess
• Biliary leaks

20
Q

Diagnostic criteria of Acute cholangitis /

A

Diagnosis should be suspected if the patient
• Has ONE of the following (AND)
o Fever or shaking chills
o Laboratory evidence of an inflammatory response (Abnormal WBC/ Increased CRP/ Other changes suggestive of inflammation)

• Has ONE of the following
o Jaundice
o Abnormal liver chemistries (Increased AST/ ALT/ ALP/ GGT)

Diagnosis is considered definite if, in addition to meeting the criteria for a suspected diagnosis
• Has BOTH of the following
o Biliary dilation on imaging
o Evidence of an etiology on imaging such as stone, stricture or stent

21
Q

First-line investigations for acute cholangitis

A

Blood:

 CBC with differentials: Leukocytosis with neutrophil predominance
 Clotting profile
 Inflammatory markers: ↑ ESR and CRP
 LFT: ↑ ALP and GGT (Cholestatic pattern) + ↑ Conjugated bilirubin
 RFT
 Urinalysis: Conjugated bilirubin
 Blood/ Bile culture + antibiotics susceptibility test

Radiological:

Transabdominal ultrasound (USG)

Endoscopic retrograde cholangiopancreatography (ERCP)

Magnetic resonance cholangiopancreatography (MRCP)

22
Q

First-line management of acute cholangitis

A

General:

  • Monitor vitals for shock
  • Manage sepsis
  • Supportive fluid resuscitation

Medical:

  • Analgesics
  • IV fluid resuscitation
  • IV antibiotics: Cefuroxime, Metronidazole, Piperacillin + Tazobactam

Biliary decompression and drainage:

  • Endoscopic = ERCP
  • Radiologic (Percutaneous) = PTBD/ Percutaneous cholecystostomy
  • Surgical = Decompression by ECBD
23
Q

Surgical treatment for acute cholangitis

Complications

A

Options

o Endoscopic = **ERCP**
o Radiologic (Percutaneous) = **PTBD/ Percutaneous cholecystostomy**
**o Decompression by ECBD**

(Bypass/ Resection)

Complications:

Perforation, bleeding from papillotomy, pancreatitis

24
Q

ECBD and surgical biliary drainage for acute cholangitis

Indications for each

A

ECBD:

Failed endoscopic drainage/ Deterioration despite Tx

Open approach for emergency

Surgical drainage:

Choledocholithiasis: Laparoscopic/ Open ECBD with removal of stones and placement of T-tube (OR) Cholecystectomy

Malignant biliary obstruction (MBO): Whipple’s or Bypass (Hepaticojejunostomy/ Choledochojejunostomy)

25
Q

ERCP interventional modalities

A

Papillary balloon dilation (Balloon sphincteroplasty)

Stone retrieval: Balloon catheter, Baskets

ERCP with endoprosthesis (endoscopic stenting)/ Nasobiliary catheter

MBBS IV - Junior Clerkship WCS (131 decks)

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