Lecture 7 - Biliary Flashcards
PRESENCE of stones in gallbladder
composed of either cholesterol or calcium bilirubinate
cholelithiasis
women 2x more likely
What are the noteworthy risk factors for cholelithiasis?
Age>40 (forty) Female Pregnancy (fertile) Obesity (fat) Flatulent
Family Hx
(the F’s… remember)
Protective factors for cholelithiasis?
coffee
statins
phys activity
diet rich in poly/monounsaturated fats
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?
acute cholecystitis
Tx for cholelithiasis?
None if asymptomatic
NSAIDs for intermittnet, mild biliary colic
Cholecystectomy is only indicated for continued pn or frequent cholecystitis
Acute cholecystitis is usually due to what?
Gallstone > 90% , attack typically preceded by large, fatty meal
(acalculous cholecystitis in remainder… consider in critically ill patients… associated w/ high mortality)
Clinical presentation of acute cholecystitis?
Sudden onset of persistent steady RUQ pn
(may radiate to shoulder/back; biliary colic that has not resolved after 6 hours)
Nausea/vomiting
FEVER
Ill-appearing patient, lying still on the exam table
RUQ TTP
Abd muscle guarding
Pos Murphy’s sign (palpate last)
Acute cholecystitis
jaundice is uncommon and should raise suspicion for more serious process
Patient expires deeply while examiner palpates the are of the gallbladder fossa. Deep inspiration leads to increased discomfort and the patient catching their breath
pos murphy’s sign
acute cholecystitis
Labs for acute cholecystitis…
CBC = leukocytosis
Nonspecific elevations of ALK PHOS/AST/ALT
What should it NOT show?
Acute cholecystitis should NOT have an increase in bilirubin (should raise suspicion for a more serious process)
Should NOT reveal a cholestatic pattern
Diagnostic radiographs for acute cholecystitis…
- First test?
- Test for function?
- First test for acute cholecystitis is a RUQ US… showing wall thickening/sonographic Murphy’s sign
- cholescintigraphy/HIDA can show function but is rarely necessary (unless US is ambiguous)
Complications of acute cholecystitis
- Gangrenous cholecystitis… common in whom?
- Perforation (common)
- Cholecystoenteric fistula
- gallstone ileus… result of passing through fistula, usually in terminal ileum
Gangrenous cholecystitis is the most common complication in diabetics or elderly. It presents w/ sepsis in addition to common symptoms
Chronic cholecystitis…
Repeated episodes of acute cholecystitis or chronic irritation of the gallbladder wall
Develops in whom?
May result in what?
Develops in patients who are poor surgical candidates
May result in porcelain bladder (intramural calcification of the gallbladder wall…)
Tx for acute cholecystitis?
- Admission for supportive care (IV fluids, pain, abx)
2. Laparoscopic cholecystectomy (pending severity)
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?
Choledocholithiasis
May lead to cholangitis (an obstruction of the biliary tract)
Severe biliary colic
RUQ or epigastric pn
Nausea/vomiting
(possibly intermittent jaundice)
choledocholithiasis
Choledocholithiasis will have a cholestatic pattern, meaning what?
Higher elevations of ALK PHOS and bilirubin (vs AST/ALT)
Diagnostic testing for choledocholithiasis?
First do a RUQ US
Then, an ERCP for confirmation and therapy
TX for choledocholithiasis?
As opposed to simple cholelithiasis, ENDOSCOPIC STONE REMOVAL IS ALWAYS INDICATED (even in asymptomatic patients)
Followed by laparoscopic cholecystectomy
Complications of choledocholithiasis?
Ascending cholangitis
Pacnreatitis
Charcot triad?
For acute cholangitis (aka ascending cholangitis)
RUQ Pain
Fever/chills
Jaundice
Acute cholangitis…
Reynold’s Pentad?
Meaning Acute Suppurative Cholangitis (**EMERGENCY)
RUQ pain Fever/chills Jaundice AMS HOTN
Labs for acute cholangitis?
CBC = leukocytosis Hepatic panel = Cholestatic pattern Blood cultures (for offending organism)
Elevated amylase
Elevated CRP
Acute cholangitis tx?
ADMISSSION (supportive care/abx)
ERCP (for drainage/obstruction removal)
Surgery (only if ERCP fails/is unavailable)
Cholecystectomy (once infxn is cleared)
Increased immune response to intestinal endotoxins
Strong association w/ IBD (UC > Crohn)
Presents w/ obstructive jaundice (fatigue, pruritus, anorexia, indigestion)
Primary sclerosing cholangitis
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)
Cholangiocarcinoma (carcinoma of the biliary tree)
Courvoisier sign?
Palpable gallbladder w/ painless obstructive jaundice
also associated w/ pancreatic cancer
WHen should the diagnosis of carcinoma of the biliary tracct be considered?
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
