LEC 1: GALLBLADDER

where is an uncommon place to get a stone but a common place to get a tumor?

the common hepatic duct

where is the m/c site for a stone to get stuck?

Hartmann's pouch

what is a stone in the CBD called?

choledocholithiasis

where can stones get stuck and cause pancreatitis?

sphincter of oddi

why is it hard to visualize the head of the pancreas on US sometimes?

b/c bowel gas in the duodenum can obstruct it

how does a patient with an obstruction in the CBD look?

more jaundiced and sicker

what does CCK do?

contracts the gallbladder

where are bile salts synthesized?

in the hepatocytes from cholesterol

what imaging do we inject CCK into a patient?

a HIDA scan

what occurs if there is problems with the enterohepatic circulation?

bile acids build up in the intestine and cause severe diarrhea

what are bile salts made of and what do they form?

made of: cholate & chenodeoxycholate

form: micelles

what is the m/c composition of stones?

cholesterol

why are some gallstones pigmented?

because they contain Ca2+ & blood products (from hemolytic diseases)

what is not a good test for gallstone disease?

xray

what are the RFs for gallstones?

fat, female, fertile, 40s (not always), crohn's disease, cirrhosis, hx of drug & ETOH use, contraceptives & NSAIDs

who are cholesterol stones m/c in?

F>M (3:1), native americans, blacks in america

what is a prereq for cholesterol stones?

excessive cholesterol in relation to micelle carrying capacity (due to dec bile salts & inc cholesterol formation)

what is the reason for gallstones?

hepatocytes, not malfunction of the gallbladder

are cholesterol stones radiopaque or radiolucent?

radiolucent

what do pigmented stones look like and what do they consist of?

black or brown stones, usu <1cm, irregular and formed in the gallbladder

consist of: Ca2+ bilirubinate, bilirubin polymers, CaPO4

are pigmented stones related to obesity?

NO!

who do we see pigmented stones in?

pt's w/ cirrhosis & hemolytic disease

what does obstruction of the CBD cause?

pain, jaundice, pruritis, infection & biliary cirrhosis

what does obstruction of the cystic duct cause?

cholecystitis; biliary pain which persists and causes infection

what causes abdominal pain?

distention of the intestines

What is the 1ST TEST FOR SCREENING GALL STONES?

SONOGRAM; doesn't tell you if gallbladder is diseased but can show gallstones or dilation of the ducts

does a patient always have to have stones on a sonogram?

NO, a patient can have a clean US and be doubled over in pain (perforation, infx, tumor, dysfxn, & obstruction of cystic artery)

what is the BEST TEST FOR GALLBLADDER FUNCTION?

HIDA scan (usu pt will be in pain after injection of CCK)

what is the m/c side effector ERCP?

pancreatitis

what causes acute cholecystitis?

stone lodged in Hartmann's pouch or cystic duct

what may occur in AIDS pt's?

acute cholecystitis caused by infectious process

what are the s/sx of acute cholecystitis?

usu precipitated by large fatty meal w/ sudden severe pain which is localized to the epigastrum or R hypochondrium, n/v, RUQ tenderness, guarding, fever, pain radiating to back & scapula

what do we see on labs of pt's w/ acute cholecystitis?

mildly elevated WBCs, inc alk phos, inc AST/ALT, amylase may be inc

what is useful for dx of acute cholecystitis?

HIDA scan

what are some complications of acute cholecystitis?

gangrene of gallbladder, cholangitis, charcots triad

what is charcot's triad?

fever, jaundice, RUQ pain (looks like sepsis)

what is the m/c organism that causes cholangitis & what should we prophylax with?

E. coli & gram - coverage abx pre op

how do we tx acute cholecystitis?

NPO ALWAYS & IVF, hydromorphone for pain, abx, cholecystectomy

what is choledocholithiasis?

stone passing into the CBD from the gallbladder

what are the s/sx of choledocholithiasis?

30-40% asymp, biliary colic, jaundice, light stools, RUQ pain, fever, dark urine, n/v

what can we see with choledocholithiasis?

Courvoisier's Law (palpable distended, nontender gallbladder)

what is courvoisier's law also indicative of?

neoplastic obstruction of the CBD

what labs do we see in pt's w/ choledocholithiasis?

elevated WBC, bilirubin, AST, alk phos

what imaging do we get for choledocholithiasis?

sono --> CT --> ERCP

what do we get a CT to see?

CBD dilation, stones, and if pancreas is involved

what else can cause dilation of the CBD?

prior cholecystectomy, infx/stone, pancreatic mass

what is the tx for choledocholithiasis?

IV abx prophylaxis for everyone!!:

- Amp& gent & flagyl

-or cipro & 3rd gen ceph

-ivanz

-IVF

-ERCP or PTC

what is sclerosing cholangitis?

benign non-bacterial chronic inflammatory narrowing of the bile ducts (commonly the entire duct system)

what type of pt's typically have sclerosing cholangitis?

pt's w/ inflammatory bowel disease (usu see young pt's)

what type of onset is sclerosing cholangitis?

insidious

what are the s/sx of sclerosing cholangitis?

jaundice, pruritis, progressive inc in bilirubin, ALK PHOS 3x the norm

what do we think when we see a young pt on cholestyramine?

sclerosing cholangitis

how is sclerosing cholangitis dx?

ERCP establishes dx & is used to tx

what does ERCP show w/ sclerosing cholangitis?

shows diffuse or focal, irregular ductal narrowing w/ dilation in between (beaded appearance)

what is the tx for sclerosing cholangitis?

cholestyramine for pruritis, endoscopic or percutaneous balloon dilation of stricture & stent placement, liver transplant

what is the m/c gallbladder cancer?

adenocarcinoma & spreads to hilar lymph nodes & the livre

how does a pt w/ gallbladder cancer present?

unremitting jaundice, acute cholecystitis w/ palpable mass, chronic RUQ pain, advanced distant metastasis

how is gallbladder cancer dx?

US, CT, ERCP

what is cholangiocarcinoma?

cancer of the ductal system

what is cholangio carcinoma seen with?

Klastskin tumor

what is a klatskin tumor?

tumor which arises @ the bifurcation of the common hepatic duct

how does pt present w/ cholangio carcinoma?

fever, unremitting jaundice, abd pain, wt loss

"pale, thin, cachectic, can't eat"

what do tumors of the CBD, sparring the cystic duct produce?

jaundice w/ a non tender gallbladder (courvoisier's law)

what is the whipple procedure good for?

only good if pt has distal disease (not for klatskin tumor)

what do we see on labs of a pt w/ cholangio carcinoma?

serum bili >10, inc alk phos, serum chole, PT

how is cholangio carcinoma dx?

US, CT, ERCP

how is cholangio carcinoma tx?

whipple, localized tumor resected, spread to nodes: palliative measures (stent placement)