Nu 735 GI I /Cholecystitis

Question 1

Gallbladdre Overview

Answer 1

• Position Unver Liver, RT UQ
• Function: Storage of BIle, combintation of fluids, fats, and cholesterol
• Biles helsp to break down fatty foot in intestines
• When normal function disturbed, gallstones causing obstructio
• Galltones is harden deposits if Digestive fluids that can form in Gallbladder
• Acute Inflammation of Gallbladder usually follow obstruction in cystic Ductc by the stone

Question 2

Acute Inflammatio of the Gallblader

Answer 2

• Actute inflammation of the Gallbladder:
  Obstruction of the Cystic Duct
• Inflammatory response awoke by three phases:
  1. Mechanical Inflammation
  2. Chemical Inflammation
  3. Bacterial inflamation

Question 3

3 Phases of Inflamation

Answer 3

1. **Mechanicla Inflammation **
   Due to increased pressure & distension
   Resultiing in Ischemia of gallbladder of intercostal wall
2. **Chemial Inflammation **
   Release of cytokines and othe mediators leading to inflammation
3. **Bacterial Inflammation **
   50 to 60 % of pt
   E/coli, Klemsiella spp, Streptococcus spp, Clostridium spp

Question 4

Acute Cholesystitis
Clinical Findigs and DX

Answer 4

** Stones Becomes Impacted in the CYTIC DUCT **
Inlammation develops behind Ostruction
>90% of cases
* Acalculous Cholecysms
RUQ pain and Unexpalaned Fever
** S/s : **
RUQ pain (Murphy sigh)
Fever
N/V
Jaundice in 25% (most likely due to CHOLEdochouthiasis or other )

Question 4

Acute Cholesystitis
Clinical Findigs and Dv

Imaging

Answer 4

** Hinda **
* Higher Specificity /Sencitivity
* * Gallbladder Dyskinesia ( when gallbler not function ; Gallbler EF <35 %
* HINDA indication : If pt show no US stone but still have temps and RUQ pain

**Gallbladder US **
More commontly used
Results with inflammation
If determien stone on US no need for HIDA scan

Question 5

Acute Cholesystitis
Clinical Findigs and Dv

Labs

Answer 5

Elevated WBC 12,000 to 14,000
Elevated LFT
Amylase mod elevatio

Question 6

Actue cholecystitis
TX plan

Answer 6

**Initiate Conservative Management **
* NPO
* IV Pain Rx, Fluids and ABX
Consult General Surgery

Question 7

Actue Cholecystitic
Antibiotics

Answer 7

Not severe: Rocephin 1 G Q 24 H +
Flagyl 500 mg Q 6 hrs

Sever Cases: Cipro 400mg Q 12 hrs +Flagy

Question 8

Labaroscopic
Elected NOn Surgical

Answer 8

• Laparoscopic Cholecystectomy and IOC**
• 24 hrs of admission
• **Elected Non-Surgical: **
• Monitor for Necrosis or Cholangitis
• DM, obese Elderly high risk
• Gangrene of Perforation
• Mandatory cholecystectomy

Question 9

Choledocholithiasis
OVERView

Answer 9

**Cheledocholithiassis : measn BILE DUCT STONes **

• 15% of patients with Gallstones HAVE CHOLEDOCHOLITHIASIS (means BILE DUCT STONES)
• Occurrence: % increases with age
• Frequency: 50% of elderly with gallstones

Bile Duct Stones Orginate in Gallbladder
But can spotenious form in the Bile Duct
**Bile Duct Obstruction >30 days:
* Liver Damage
* Cirrhosis
* Hepatic Failure : Portal Hypertansion

Question 10

Choledecholithiasis
Clinical Findings and DX

Answer 10

*** Signs & Symptoms: all suggest present of bile duct stone **
* abdominal pain: Rt UQ pain that last hours
* Fever: chills and fever associate with pain
* Jaundice associated with abdominal pain
* Nausea & vomiting
* Elevated LFT‘s

• If lead to obstruction then **pancreatis and cholangitis can occur **

Question 11

Choledecholithiasis
Imaging Dx

Answer 11

*** Ultrasound & CT scan **
* Dilated common bile duct (CBD)
o Normal CBD diameter <6 mm (no bigger)

*** Magnetic Resonance Cholangiopancreatography (MRCP) MRI abdomen
>Identifies bile duct stone cocurate dx
> Can be done with or w/o contrast to identify etiology
* No need for contrast if you are looking for retain stone

Question 12

Choledocholithiasis
Treatment Plan

Answer 12

• Consults GI and General surgery
  **ERSP: **
• Sphincterotomy & stone extraction
• Stent placement: W Replaced/removed 3-6 months
• Risk for cholangitis & pancreatitis

**Procedure Of choice: **
Choledocholithiasis complicated by acute cholangitis
In this case ERCP with Sphincterotomy becomes urgen procedure of choice over surgery
Needs to be done within 2 hrs

Question 13

Choledocholithiasis and Cholecystitis (stone in bile duct)

Answer 13

• ERCP for stone extraction and followed by lap chole in 72 hours
• Cholecystectomy deferred 2 weeks without cholecystitis

Question 14

Postoperative Antibiotics

Answer 14

o Not routinely administered after surgery unless person have Infected biliary tract

o **Infected biliary tract if infected **
o Unasyn 3 G IV q6h or Zosyn 3.375 G IV q6h or
o Rocephin 1 G IV q24H
o Until resulted C & S