obstructive jaundice and biliary calculus disease Flashcards
clinical presentation of ductal adenocarcinoma of the pancreas
abdo pain
weight loss, anorexia, cachexia
nausea, vomiting, diarrhea, steatorrhea
hepatomegaly
RUQ or epigastric mass
jaundice
dark urine
ascites
courvoisier’s sign (painless enlarged gallbladder with mild jaundice)
what is a diagnostic approach to pancreatic cancer
CT or U/S to ID and visualize mass
if no mass seen, can do ERCP/MRCP and/or endoscopic U/S–> if low suspicion of malignancy, can do serologic testing for tumour markers
proceed to biopsy
treatment of pancreatic cancer
if resectable–> surgical or laparoscopic resection
if borderline resectable–> neoadjuvant therapy in addition to surgical
if unresectable–> consider nonsurgical tx
what causes biliary colic
a stone obstructing gallbladder outflow
what do you ask on history for biliary colic
associated symptoms
jaundice
color of urine or stool
fever or weight loss
N/V/D
pain that radiates to the SHOULDER, pain that occurs over a few hours but gets better, pain that is worse with fatty meals
fatty food intolerance
what are some symptoms of biliary colic
several hours post ingestion of large fatty meal
epigastric/RUQ
pain that lasts several hours and is constant during that time, but then resolves
no fever or jaundive
what is the first choice imaging test for biliary tract disease
U/S
should you operate on asymptomatic gallstones
no
operate is symptomatic
what are the three types of gallstones? which are most common?
- cholesterol—most common
- brown pigment–from pathologic biliary stasis
- black pigment–from excessive heme turnover
what are the risk factors for cholesterol gallstones
age
sex
pregnancy
obesity
ethnicity (aboriginal)
treatment for gallstones
analgesia
outpatient surgical opinion with or without elective cholecystectomy depending on frequency of symptoms
patient education
what are the common finding on ultrasound for cholecystitis
stone in neck of gallbladder
wall thickening more than 4mm
peri-cholecystic fluid
sonographic murphy’s sign
what liver enzymes may be elevated in inflammation/injury to the biliary tree
ALP
GGT
what differentiates cholecystitis from biliary colic
fever and elevated WBCs
how do you manage cholecystitis
NPO with IV fluids
abx to cover gram negative organisms
surgery–> MIS or open for cholecystectomy
do surgery early if possible, within 3-4 days
*if more than 5-7 days of symptoms, surgery may not be safe
can also consider percutaneous cholecystostomy to place a tube for drainage and maybe remove later
what type of bilirubin is “direct”
conjugated–post hepatic
*if this is elevated, it is due to obstruction
what is choledocholithiasis
stone in the CBD
symptoms of choledocholithiasis
obstruction to flow leads to pain, JAUNDICE with or without fever and elevated WBCs
investigations for choledocholithiasis
U/S for duct dilation and stone
treatment for choledocholithiasis
- ERCP–> helpful but not entirely benign
- -diagnostic imaging modality
- -remove stones
- -widen the sphincter
- -place a stent - surgery to remove the stones
- -open common bile duct exploration is uncommon - decompress proximally via percutaneous trans-hepatic biliary drainage
other options:
MRCP (high res images of biliary tree, pancreas can show subtle anatomic variations/strictures/masses)
endoscopic U/S
what does charcot’s triad describe
classic triad of symptoms of cholangitis
RUQ pain
fever
jaundice
what is Reynaud’s pentad
charcot’s triad (RUQ pain, fever, jaundice) for cholangitis plus SHOCK and CONFUSION
treatment for cholangitis
rescuscitation (ABCs) with fluids and abx with or without ICU if severe or very shocky
urgent ERCP
what most commonly causes pancreatitis
alcohol and gallstones
how does pancreatitis usually present
LUQ pain
investigations for pancreatitis
CBC, lytes, LIPASE
U/S to look for stones
CT to look at the pancreas and direct treament
what is gallstone pancreatitis
accounts for nearly 40% of acute pancreatitis, with stones passing or obstructing in the SPHINCTER OF ODDI
how do you treat gallstone pancreatitis
resuscitate with fluids, NPO, analgesics
wait and see with close monitoring
if after 48 hours the patient continues to get worse, then may do ERCP for stubborn stones and often move gallbladder too
*80-90% get better over time with spontaneous passage of the stone in the first 24-48 hours
list 2 possible complications from not removing gallstones/the gallbladder
rare
- mirizzi’s syndrome—dilated cystic duct from stone can imact the CBD and cause obstruction
- gallstone ileus–mechanical obstruction NOT an ileus due to chronic inflammation causing cholecysto-enteric fistula
- -stone moves thru the small bowel and lodged at the narrow areas, most commonly at terminal ileum/ileocecal valve
- -REQUIRES OR–open terminal ileum, milk proximally, remove a healthier section of small bowel - maybe gallbladder cancer
what is courvoisier’s sign/law
in the presence of a palpably enlarge gallbladder which is non-tender and accompanied by mild painless jaundice, the cause is unlikely to be gallstones and is more likely malignancy
what should you suspect in a patient with non tender palpable RUQ mass?
unlikely to be stone related MUST rule out malignancy
malignancy could be of gallbladder, bile duct, head of pancreas
