1. EVALUATION AND TREATMENT OF GALLBLADDER DISEASE Dr. Kellen Gallstone

2. EVALUATION AND TREATMENT OF GALLBLADDER DISEASE Dr. Kellen Gallstone Not to be confused with Galster Stones 3. OBJECTIVES Understand disease pathology and presentation Diagnostic modalities Treatment options Improve interdepartmental relations(buy them beer!) 4. THE BASICS 5. VOCAB Biliary Colic painful passage of gallstones McMurphy Sign inspiratory arrest during deep palpation to RUQ Cholesterol Stone assoc. age, female, obese, rapid weight loss, CF, parity (by far the most common) Pigmented Stone contain calcium 2/2 chronic intravascular hemolysis (sickle cell, spherocytosis) or biliary infections Magnetic resonance cholangiopancreatography (MRCP) Endoscopic Retrograde Cholangiopancreatography (ERCP) 6. ANATOMY 7. CHOLELITHIASIS Gallstones in the gallbladder are asymptomatic in 80% of patients. Clinically manifests as biliary colic during passage of a stone or ductal blockage 2/2 stone. Exam Most pt present with postprandial upper abdominal pain, occasionally radiates to the right subscapular are or the epigastrium Acute onset of pain with gradual relief, associated with nausea/vomiting, dyspepsia and fatty food intolerance Mild tenderness to palpation w/o guarding or rebound Diagnosis LFT are normal, US Shows gallstones with an 85-90% sensitivity Oral cholecystography ipanoic acid is 95% sensitive, useful when gallbladder can not be visualized Plain film only visualizes 10% of gallstones 8. CHOLELITHIASIS ULTRASOUND 9. CHOLELITHIASIS Treatment Pain relief w/ antispasmodics, NSAIDs and Narcotics Correction of dehydration and electrolyte imbalances 2/2 N/V Antiemetics Avoidance of fatty foods PO bile acid chenodeoxycholate or ursodeoxycholate to dissolve stones Elective outpatient cholecystectomy 10. EARLY VS LATE CHOLECYSTECTOMY Mortality Pancreatitis Morbidity (other) Hospital Stay 11. CHOLEDOCHOLITHIASIS Gallstones in the common bile duct Exam RUQ pain, episodic colic, fever, occasional jaundice and occasional pancreatitis Diagnosis Alkaline phosphatase and total bilirubin Ultrasound shows dilated common bile duct MRCP - useful for visualizing ductal involvement 12. CHOLEDOCHOLITHIASIS ULTRASOUND 13. CHOLEDOCHOLITHIASIS ULTRASOUND 14. CHOLEDOCHOLITHIASIS Treatment ERCP w/ sphincterotomy for stone removal Followed later by semi-elective cholecystectomy 15. CHOLECYSTITIS Inflammation of the gallbladder 2/2 blockage of the cystic duct (2-12% acalculous). Gallbladder becomes distended, inflamed, superinfected and possible gangrenous. Exam Pain may initially be described as colicky but will progress to constant Murphys Sign, fever, leukocytosis, possible guarding or rebound tenderness More sever and longer than those of biliary colic, w/ N/V Diagnosis Ultrasound demonstrates stones, thickened gallbladder wall, +/- pericholecystitis fluid, biliary sludge, w/ + Ultrasonographic murphy's sign HIDA scan when Ultrasound in equivocal, non-visualized gallbladder/cystic duct 1 hour after receiving IDA (iminodiacetic acid) is highly suggestive of Cholecystitis. CT scan is 92% sen. and 99% spec. LFTs and WBCs normal to mildly elevated 16. CHOLECYSTITIS 17. CHOLECYSTITIS 18. CHOLECYSTITIS Treatment Correction of dehydration and electrolyte imbalances 2/2 N/V Nasogastric suctioning to decompress the stomach biliary secretions Surgical consult Pain control with Narcotics Hospitalize and begin a single 2nd or 3rd generation cephalosporin Cholecystectomy is definitive treatment or percutaneous drainage in an unstable patient. 50% resolve spontaneously, hemodynamically stable patients with significant medical problems can be managed medically for 4-6 before semi-elective surgery 19. ACUTE BACTERIAL CHOLANGITIS Infection of the biliary tree secondary to common bile duct obstruction/stasis. Exam Charcots Triad: RUQ pain, Jaundice, Febrile (seen in 70% of patients) Reynolds Pentad: RUQ pain, Jaundice, Febrile + Shock and AMS Risk Factors Caused by gram (-) enterics: E. coli, Klebsiella, Enterococcus, Bacteroides, and Enterobacter Gallstones (85%), bile duct stricture, ampullary carcinoma, pancreatic pseudocyst. Diagnosis Leukocytosis (80%), hyperbilirubinemia (80%), Alkaline Phosphatase 20. CHOLANGITIS Treatment Fluid resuscitation Blood Cx Broad-Spectrum IV Abx: ampicillin-sulbactam (Unasyn), piperacillin- tazobactam (Zosyn), ceftriaxone + metronidazole, meropenem, or ampicillin + gentamycin + metronidazole Consider ICU admission Consult Surgery, GI, or IR Early intervention w, ERCP, percutaneous transhepatic cholangiography (THC), or open decompression 21. RARE AND OR SERIOUS Emphysematous cholecystis - If air is seen in the gallbladder on abdominal x-ray or ultrasound this is a life threatening condition found in older men classically associated w/ DM and caused by Clostridium perfringes. Porcelain Gallbladder linear or punctuate calcifications w/in the gallbladder wall on plain film. High incidence of carcinoma. Referral for elective cholecystectomy. Commonly women in their 50s. Acalculous cholecystitis - Inflammation of the gallbladder 2/2 blockage of the cystic duct by pathology other than stones. Tumor, lymphadenopathy, fibrosis, parasites, and kinking of the duct. AIDS Cholangiopathy associated with CD4 >200. These patients experience bile duct strictures, papillary stenosis, and sclerosing cholangitis. The infection are caused by CMV, Cryptosporidium, microsporidia, or Mycobacteria avium. Presentation and treatment are similar to cholangitis. 22. RARE AND OR SERIOUS Sclerosing Cholangitis an idiopathic inflammatory disorder affecting the biliary tree. There is diffuse fibrosis and narrowing of the intrahepatic and extrahepatic bile ducts. Commonly associated with Ulcerative Colitis w/ 25% of cases appearing to be an isolated disorder. Perforation Gangrene Fistulization Sepsis Abscess 23. BLOGOSPHERE 24. A 72-year-old man with known Type 2 diabetes mellitus presents with severe right upper quadrant abdominal pain radiating to his back. He denies recent illness or surgery. Physical examination reveals fever and tachycardia, with tenderness in the right upper quadrant but no peritoneal signs. The patient is not icteric, and his pulmonary examination is unremarkable. Radiographs are ordered (image below). What is the most appropriate management? A) Obtain emergent surgery consultation B) Obtain RUQ ultrasonography C) Order complete white count and differential, electrolytes, and liver function tests D) Order CT of the abdomen E) Start fluid resuscitation 25. A 72-year-old man with known Type 2 diabetes mellitus presents with severe right upper quadrant abdominal pain radiating to his back. He denies recent illness or surgery. Physical examination reveals fever and tachycardia, with tenderness in the right upper quadrant but no peritoneal signs. The patient is not icteric, and his pulmonary examination is unremarkable. Radiographs are ordered (image below). What is the most appropriate management? A) Obtain emergent surgery consultation B) Obtain RUQ ultrasonography C) Order complete white count and differential, electrolytes, and liver function tests D) Order CT of the abdomen E) Start fluid resuscitation 26. A 72-year-old man with known Type 2 diabetes mellitus presents with severe right upper quadrant abdominal pain radiating to his back. He denies recent illness or surgery. Physical examination reveals fever and tachycardia, with tenderness in the right upper quadrant but no peritoneal signs. The patient is not icteric, and his pulmonary examination is unremarkable. Radiographs are ordered (image below). What is the most appropriate management? A) Obtain emergent surgery consultation B) Obtain RUQ ultrasonography C) Order complete white count and differential, electrolytes, and liver function tests D) Order CT of the abdomen E) Start fluid resuscitation 27. Answer: This patient has emphysematous cholecystitis, an acute infection of the gallbladder caused by gas-producing organisms. It frequently affects older men. A significant percentage of patients with this condition have underlying diabetes mellitus, and 28% to 80% have gallstones. Clostridial spp. E coli, and Klebsiella spp. Are the most common. Emphysematous cholecystitis occurs in 1% of patients with acute cholecystitis. Symptoms include RUQ pain, fever tachycardia, and hypotension. Abdominal radiographs show fluid- filled gallbladder, w/ gas in the gallbladder wall which can extended into pericholecystic tissue and perihepatic ducts. 28. A 55-year-old man presents complaining of abdominal pain of several days duration. He was in good health until he developed fever and chills, malaise, and myalgias. He got scared when his coworkers told him that his eyes were yellow. Past medical history is unremarkable. He denies any history of alcohol abuse, intravenous drug abuse, or blood transfusion. Vital signs include blood pressure 100/70, pulse rate 110, and temperature 38.8C (101.8F). Physical exam reveals scleral icterus and a tender right upper quadrant. What is the most likely diagnosis? A) Acute cholangitis B) Cholelithiasis C) Hepatic metastasis D) Pancreatic carcinoma E) Viral hepatitis 29. A 55-year-old man presents complaining of abdominal pain of several days duration. He was in good health until he developed fever and chills, malaise, and myalgias. He got scared when his coworkers told him that his eyes were yellow. Past medical history is unremarkable. He denies any history of alcohol abuse, intravenous drug abuse, or blood transfusion. Vital signs include blood pressure 100/70, pulse rate 110, and temperature 38.8C (101.8F). Physical exam reveals scleral icterus and a tender right upper quadrant. What is the most likely diagnosis? A) Acute cholangitis B) Cholelithiasis C) Hepatic metastasis D) Pancreatic carcinoma E) Viral hepatitis 30. Answer: Jaundice in the setting of a febrile illness suggests an infectious etiology. Cholangitis is an infection of the biliary tree most commonly due to bile duct obstruction from stones. Strictures, tumors, stenosis. Charcot triad is present in 70% of cholangitis patients. Other symptoms might include pruritus and hypocholic or acholic stools. Other physical findings might include hypotension, AMS, mild hepatomegaly and sepsis. Fluid resuscitation and borad-spectrum antibiotics are appropriate in patients with mild cholangitis whereas those who are more severly compromised urgently requires surgical intervention. The most common bacteria are E coli., Klebsiella and Enterobacter spp., enterococci and group D streptococci. 31. A 40-year-old woman presents with fever, right upper quadrant pain, jaundice, hypotension, and altered mental status. Laboratory test reveal elevated WBCs, bilirubin, and alkaline phosphatase levels; lipase level is normal. Ultrasound examination demonstrates cholelithiasis with a 10-mm common bile duct. What is the appropriate next step in management? A) CT Scanning B) Emergency surgery C) Endoscopic retrograde cholangiopancreatography D) Hepatobiliary imino-diacetic acid scan 32. A 40-year-old woman presents with fever, right upper quadrant pain, jaundice, hypotension, and altered mental status. Laboratory test reveal elevated WBCs, bilirubin, and alkaline phosphatase levels; lipase level is normal. Ultrasound examination demonstrates cholelithiasis with a 10-mm common bile duct. What is the appropriate next step in management? A) CT Scanning B) Emergency surgery C) Endoscopic retrograde cholangiopancreatography D) Hepatobiliary imino-diacetic acid scan 33. Answer: Patients presenting with acute cholangitis from choledocholithiasis require biliary decompression through ERCP. Acute cholangitis is an emergency of the biliary tract requiring prompt recognition and treatment. Cholangitis is often caused by obstruction of the common bile duct from stones (80%), malignancy, or stricture. Obstruction causes an increase in the intraluminal pressures within the biliary tract, resulting in pain and nausea. If not relieved continued obstruction leads to reflux of gastrointestinal bacteriainto lymphatic vessels, portal vien circulation, and subsequently systemic circulation. Seen of in less than one-third patients, the classic presentation is the Charcot triad. The WBC count and Alk Phos and bilirubin levels help suggest the diagnosis in less clear-cut cases. Significant bilirubin elevations help distinguish bile duct obstrustion from simple cholecystitis. Neither a CT scan nor a HIDA scan is helpfulin already-diagnosed cholangitis. Initial management includes aggressive fluid resuscitation and broad-spectrum Abx, but mortality rate approach 100% when obstruction is not relieved. The lowest mortality rates are achieved with ERCP which is the first- line treatment to decompress the biliary tract through removal of obstructing stones, sphincterotomy, or stent placement. If ERCP is unsuccessful, percutaneous transheoatic cholangiography w/ drainage should be considered. With a mortality rate of up to 40%, emergency surgery is preformed only after less-invasive techniques fail. 34. RECAP OF WHAT WE LEARNED Cholithiasis if symptomtic tx elective out patient Sx Steve watches the Voice, Casey watches Real House Wives (ie theyre both married) Abx for Cholangitis and Cholecystitis Cholithithasis and Choledochyllithasis only require emergent surgery in our patients 35. THINGS WE DIDNT LEARN Coconuts kill about 150 people each year. That's more than sharks. The glue on Israeli postage is certified kosher. The Guinness Book of Records holds the record for being the book most often stolen from Public Libraries. The word "lethologica" describes the state of not being able to remember the word you want. Title 14, Section 1211 of the Code of Federal Regulations (implemented on July 16, 1969) makes it illegal for U.S. citizens to have any contact with extraterrestrials or their vehicles. 36. QUESTIONS?