Lecture 7 - Biliary

Question 1

PRESENCE of stones in gallbladder

composed of either cholesterol or calcium bilirubinate

Answer 1

cholelithiasis

women 2x more likely

Question 2

What are the noteworthy risk factors for cholelithiasis?

Answer 2

Age>40 (forty)
Female
Pregnancy (fertile)
Obesity (fat)
Flatulent

Family Hx

(the F’s… remember)

Question 3

Protective factors for cholelithiasis?

Answer 3

coffee
statins
phys activity
diet rich in poly/monounsaturated fats

Question 4

Cholelithiasis (gallstones) are often asymptomatic and may be found incidentally or xray/US…

However, may cause episodic RUQ pain (biliary colic)… this is due to intermittent/partial obstruction of cystic duct which may then lead to?

Answer 4

acute cholecystitis

Question 5

Tx for cholelithiasis?

Answer 5

None if asymptomatic

NSAIDs for intermittnet, mild biliary colic

Cholecystectomy is only indicated for continued pn or frequent cholecystitis

Question 6

Acute cholecystitis is usually due to what?

Answer 6

Gallstone > 90% , attack typically preceded by large, fatty meal

(acalculous cholecystitis in remainder… consider in critically ill patients… associated w/ high mortality)

Question 7

Clinical presentation of acute cholecystitis?

Answer 7

Sudden onset of persistent steady RUQ pn
(may radiate to shoulder/back; biliary colic that has not resolved after 6 hours)

Nausea/vomiting

FEVER

Question 8

Ill-appearing patient, lying still on the exam table

RUQ TTP

Abd muscle guarding

Pos Murphy’s sign (palpate last)

Answer 8

Acute cholecystitis

jaundice is uncommon and should raise suspicion for more serious process

Question 9

Patient expires deeply while examiner palpates the are of the gallbladder fossa. Deep inspiration leads to increased discomfort and the patient catching their breath

Answer 9

pos murphy’s sign

acute cholecystitis

Question 10

Labs for acute cholecystitis…

CBC = leukocytosis
Nonspecific elevations of ALK PHOS/AST/ALT

What should it NOT show?

Answer 10

Acute cholecystitis should NOT have an increase in bilirubin (should raise suspicion for a more serious process)

Should NOT reveal a cholestatic pattern

Question 11

Diagnostic radiographs for acute cholecystitis…

1. First test?
2. Test for function?

Answer 11

1. First test for acute cholecystitis is a RUQ US… showing wall thickening/sonographic Murphy’s sign
2. cholescintigraphy/HIDA can show function but is rarely necessary (unless US is ambiguous)

Question 12

Complications of acute cholecystitis

1. Gangrenous cholecystitis… common in whom?
2. Perforation (common)
3. Cholecystoenteric fistula
4. gallstone ileus… result of passing through fistula, usually in terminal ileum

Answer 12

Gangrenous cholecystitis is the most common complication in diabetics or elderly. It presents w/ sepsis in addition to common symptoms

Question 13

Chronic cholecystitis…

Repeated episodes of acute cholecystitis or chronic irritation of the gallbladder wall

Develops in whom?

May result in what?

Answer 13

Develops in patients who are poor surgical candidates

May result in porcelain bladder (intramural calcification of the gallbladder wall…)

Question 14

Tx for acute cholecystitis?

Answer 14

1. Admission for supportive care (IV fluids, pain, abx)

2. Laparoscopic cholecystectomy (pending severity)

Question 15

Presence of gallstones in the COMMON BILE DUCT

typically as a result of a stone being thrown from the gallbladder

Resultant obstructions may lead to?

Answer 15

Choledocholithiasis

May lead to cholangitis (an obstruction of the biliary tract)

Question 16

Severe biliary colic

RUQ or epigastric pn

Nausea/vomiting

(possibly intermittent jaundice)

Answer 16

choledocholithiasis

Question 17

Choledocholithiasis will have a cholestatic pattern, meaning what?

Answer 17

Higher elevations of ALK PHOS and bilirubin (vs AST/ALT)

Question 18

Diagnostic testing for choledocholithiasis?

Answer 18

First do a RUQ US

Then, an ERCP for confirmation and therapy

Question 19

TX for choledocholithiasis?

Answer 19

As opposed to simple cholelithiasis, ENDOSCOPIC STONE REMOVAL IS ALWAYS INDICATED (even in asymptomatic patients)

Followed by laparoscopic cholecystectomy

Question 20

Complications of choledocholithiasis?

Answer 20

Ascending cholangitis

Pacnreatitis

Question 21

Charcot triad?

For acute cholangitis (aka ascending cholangitis)

Answer 21

RUQ Pain
Fever/chills
Jaundice

Question 22

Acute cholangitis…

Reynold’s Pentad?

Meaning Acute Suppurative Cholangitis (**EMERGENCY)

Answer 22

RUQ pain
Fever/chills
Jaundice
AMS
HOTN

Question 23

Labs for acute cholangitis?

Answer 23

CBC = leukocytosis
Hepatic panel = Cholestatic pattern
Blood cultures (for offending organism)

Elevated amylase
Elevated CRP

Question 24

Acute cholangitis tx?

Answer 24

ADMISSSION (supportive care/abx)

ERCP (for drainage/obstruction removal)

Surgery (only if ERCP fails/is unavailable)

Cholecystectomy (once infxn is cleared)

Question 25

Increased immune response to intestinal endotoxins

Strong association w/ IBD (UC > Crohn)

Presents w/ obstructive jaundice (fatigue, pruritus, anorexia, indigestion)

Answer 25

Primary sclerosing cholangitis

Question 26

Insidious – usually diagnosed during surgery of the gallbladder or biliary tract

Cancer of the bile ducts

Presents w/ obstructive jaundice (painlss but dilated biliary tree)

Answer 26

Cholangiocarcinoma (carcinoma of the biliary tree)

Question 27

Courvoisier sign?

Answer 27

Palpable gallbladder w/ painless obstructive jaundice

also associated w/ pancreatic cancer

Question 28

WHen should the diagnosis of carcinoma of the biliary tracct be considered?

Answer 28

When signs of biliary obstruction are present (jaundice, abnormal LFTs w/ cholestatic pattern, bile duct dilation on imaging)….
With no alternative explanation (so, no choledocholithiasis or pancreatic head lesion)

Also consider, in patients w/ isolated intrahepatic mass with NORMAL AFP levels