Disorders of the Gallbladder

What are some RFs associated with cholelithiasis?

Age, female, Pregnancy (hormones) obesity, genetics, diet, family history

**FAT, FEMALE, FERTILE, 40s

A pt presents with episodic epigastric RUQ pain and nausea. She states that it began abruptly after eating a large fatty meal and is continuous and resolves slowly 20ms. he findings on the US are attached. ---- what is the likely dx?

cholelithiasis

For an asymptomatic pt with cholelithiasis what is the tx?

observe

For an symptomatic pt with cholelithiasis what is the tx?

Laparoscopic cholecystectomy – surgical intervention of choice

What is the diagnostic imaging of choice for cholelithiasis?

ultrasound TOC

What is 90% of the time associated with gallstones bc of impaction of the cystic duct?

acute cholecystitis

A pt presents with fever, N/V, and complaints of steady severe pain in the epigastric RUQ area. Upon PE you see some jaundice and obtain a + murphy's sign. An US (attached) shows GB wall thickening, pericholecystic fluid, and sonographic murphys. --- what is the likely dx?

cholecystitis

What will an US show for suspected acute cholysititis?

GB wall thickening, pericholecystic fluid, sonographic Murphy's

What are some complications associated with acute cholysititis?

◦Gangrene of the gallbladder

◦Chronic cholecystitis → strawberry GB

◦ porcelain GB

◦Mirizzi syndrome

What is the tx for acute cholecystitis?

◦NPO, IVF, analgesics, IV abx- Ceftriaxone (Rocephin) 1-2g Qdaily + metronidazole (Flagyl) 500mg QID

◦Laparoscopic cholecystectomy usually recommended

What occurs due to gallstones in the common bile duct and the risk increases with age?

choledocholithiasis and cholangitis

A pt presents with biliary colic pain. Upon PE you note jaundice-- what is the likely dx?

choledocholithiasis and cholangitis

What is the tx for choledocholithiasis and cholangitis?

Stone extraction with ERCP

Surgery: cholecystectomy with IOC

What is a biliary infection that can occur secondary to obstruction CBD by gallstones and is an EMERGENCY?

acute cholangitis

A pt presents with fever/chills, RUQ pain, and AMS. PE notes jaundice. --- what is the likely dx?

acute cholangitis

What composes charcots triad that is associated with acute cholangitis?

fever/chills, RUQ pain, jaundice

What composes Reynolds pentad that is associated with acute cholangitis?

fever/chills, RUQ pain, jaundice + shock and AMS

What are the diagnostic tools associated with acute cholangitis?

CBC

CMP

Prolonged PT

US, CT

ERCP (Endoscopic retrograde cholangiopancreatography (ERCP) *Urgent: allows procedure

For a pt with community acquired acute cholangitis--- what is the tx?

IV Ciprofloxacin + metronidazole (Flagyl)

◦Surgery once stable: cholecystectomy

For a pt with hospital acquired acute cholangitis--- what is the tx?

Piperacillin-tazobactam (Zosyn) or Meropenem

◦Surgery once stable: cholecystectomy

What can occur due to surgical anastomosis or injury to the biliary tree?

biliary stricture

What is a complication associated with biliary stricture?

Cholangitis

What are the diagnostics for biliary stricture?

◦ERCP>MRCP

◦CT

What is the tx for biliary stricture?

◦ERCP

◦Dilation and/or stent via EUS- Metal stents generally only used if life expectancy <2 years

◦Surgical intervention- Choledochojejunostomy or hepaticojejunostomy

What is MC in males, strongly associated with UC (90%), and occurs due to:

DIFFUSE inflammation of the biliary tract → fibrosis → strictures

primary sclerosing cholangitis

What diagnostics are used in the diagnosis of primary sclerosing cholangitis?

• MRCP, ERCP

• + P-ANCA

• ALK, GGT also elevated

PBCIW

PBCIW → Primary Biliary Cirrhosis (Cholangitis) “Intrahepatic” “Women”

• helps remember PBC is Idiopathic autoimmune disease of intrahepatic small bile ducts

• MC in middle aged women

PSC is the opposite, doesn’t involve intrahepatic and typically occurs more in males

A pt presents with complaints of fatigue and pruritis. Upon PE you note jaundice, RUQ pain, hepatomegaly, and some signs of portal HTN. The diagnostics show + anti-mitochondrial Ab. --- what is the likely dx?

primary biliary cirrhosis (cholangitis)

What are the diagnostic tools for primary biliary cholangitis?

+ anti-mitochondrial antibody = hallmark*

↑ ALP w/ ↑ GGT, GGT often strikingly elevated, ↑ ALT, AST, bilirubin

Elevated IgM

Liver bx

What is the tx for primary biliary cholangitis?

Ursodeoxycholic acid 1st line