what is the size of the gallbladder?
10 cm
the gallbladder is capable of holding ______ of bile
50 ml
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what is the size of the gallbladder?
10 cm
the gallbladder is capable of holding ______ of bile
50 ml
what is the function of the gallbladder?
receive, store & concentrate bile
- stimulated by cholecystokinin, usually over 10-15 mins
what is cholelithiasis?
presence of gallstones w/i the gallbladder
what is cholecystitis?
inflammation of the gallbladder
- potentially w/ or w/o stones
what is choledocholithiasis?
presence of gallstones in the common bile duct
what is cholangitis?
inflammation of the bile duct(s)
- potentially affecting the entire biliary tree
what is included in liver function tests (LFTs)?
- alanine aminotransferase (ALT)
- aspartate aminotransferase (AST)
- gamma glutamyl transpeptidase (GGT)
- alkaline phosphatase (ALP)
- bilirubin
elevated AST, ALT & GGT suggest ________ injury
hepatic (liver)
- commonly due to: hepatitis, toxin/drug injury, alcohol, fatty liver, or hemochromatosis
elevated ALP & bilirubin suggest ___________ obstruction
biliary
gallstones do not just appear. how do they start?
supersaturation
- imbalance in the chemical constituents of bile that results in precipitation of >/= 1 of the components (biliary sludge)
what are the types of gallstones?
- cholesterol & mixed
- pigmented
which are more common:
cholesterol & mixed or pigmented gallstones?
cholesterol & mixed (90%)
cholesterol & mixed gallstones
most common
- characterized by their yellowish green color & soft texture
pigmented gallstones
not common (10%)
- characterized by their darker color & grain-like texture
- composed of calcium bilirubinate
- sometimes detectable on plain films
complications/clinical presentations of gallstones:
- biliary colic
- acute cholecystitis
- acute cholangitis
- acute biliary pancreatitis
- perforation of GB
- small bowel ileus
biliary colic is a ___________ obstruction of the cystic or common bile duct
transient
1 multiple choice option
clinical presentation of biliary colic
may start w/ mild, sporadic, or nonspecific complaints
- sudden onset: epigastric pain (most common), then RUQ pain which plateaus in 15 mins & usually lasts 1-4 hrs
- may refer to shoulder, chest, or back
- pain often develops 15 mins to 2 hrs after eating (nocturnal pain is common)
5 Fs (risk factors) of cholecystitis:
- female (2-3 x > male)
- forty/40 y/o (age)
- fat (obesity)
- fertile (multiparity)
- fair (caucasian)
clinical presentation of acute cholecystitis
- local inflammation
- RUQ mass, pain, fever, N/V, leukocytosis
- hx of previous episodes
- lasts > 8 hrs
- shifts from epigastrium to RUQ
- murphy's sign
- jaundice
- acalculous disorder
what is murphy's sign?
acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration
- sign of: cholecysitis
what is acalculous disorder/cholecystitis?
inflammation of the gallbladder (probably due to bile stasis) w/o stones
- more common in older, male, critically ill, TPN, surgery or trauma patients
- higher rate of complications
how can you tell the difference between biliary colic & cholecystitis?
biliary colic
- upper abdomen or RUQ pain (may refer to shoulder, chest or back)
- < 8 hrs
- may have N/V
- no TTP in RUQ
- no inflammatory signs
cholecystitis
- usually localizes as RUQ pain
- > 8 hrs
- more frequent N/V
- TTP in RUQ
- inflammatory signs
how is acute cholecystitis treated?
- NPO
- IV fluids
- NG tube (low, intermittent suction if significant vomiting)
- pain control (NSAIDs [IV ketorolac], opioids if no relief)
- antibiotics (gram - & anaerobes)
- consider severity & whether healthcare associated infection
what is acute ascending cholangitis?
bacterial infection of the biliary tract
- suppurative (to form or discharge pus usually in response to bacterial infections) condition
clinical presentation of acute ascending cholangitis
- charcot's triad (RUQ pain, fever/chills, jaundice)
- signs of sepsis (altered mentation, hypotension, shock)
what is charcot's triad?
sign of acute ascending cholangitis
- RUQ pain
- jaundice
- fever/chills
what are the typical organisms in acute ascending cholangitis?
- e. coli
- klebsiella
- pseudomonas
- anaerobes
is acute ascending cholangitis a surgical emergency?
YES!
1 multiple choice option
what is the imaging modality of choice for assessing an issue w/ gallbladder?
ultrasound
- although less sensitive for common duct stones
will plain films (radiographs/XRs) visualize cholesterol stones?
NO
- you should NOT be able to see the gallbladder on XR, if you can: beware of "porcelain gallbladder"
- porcelain gallbladder = gallbladder calcification
what is "porcelain gallbladder?"
calcium depositions in the gallbladder
- cancer until proven otherwise
- should prompt investigation
why are CT or MRI not commonly done to diagnose a disease of the gallbladder?
expensive & time consuming
what is a hepatobiliary or cholescintigraphy (HIDA scan)?
technetium labeled HIDA is injected, taken up by hepatocytes & excreted into bile
- used when looking for obstruction of cystic duct & to assess gallbladder function
____ is best for finding choledocholithiasis & can be both diagnostic & therapeutic
ERCP
will uncomplicated biliary colic show any lab abnormalities?
no
1 multiple choice option
lab abnormalities for acute cholecystitis & ascending cholangitis
- leukocytosis w/ "left shift"
- elevated liver enzymes (ALP & bilirubin)
- elevated amylase (acute pancreatitis)
ascending cholangitis may also have positive (+) ________________
blood cultures
Gallstones present but pt is asymptomatic … treatment =
none (w/ exceptions)
treatment in an acute episode =
- NPO
- analgesics
- antibiotics
- consider surgery (2-3 days)
oral dissolution therapy =
ursodiol (Actigall)
- last ditch effort; usually a poor surgical candidate; 50% recurrence rate
what are the surgical treatment options?
- laparoscopic cholecystectomy
- open subcostal incision
if there is a slightly higher incidence of bile duct injury w/ laparoscopic cholecystectomy, why is it the preferred surgical treatment option?
- reduced postop pain & recovery
- looks better cosmetically
atypical symptoms:
- chest pain
- epigastric pain
- nonspecific abdominal pain
- early satiety
- abdominal distention/bloating
- nausea
what is cholangiocarcinoma?
cancer of the biliary tree
- can be intrahepatic, extrahepatic or both
- periductal or intraductal
s/s of cholangiocarcinoma:
depends on location of tumor
is most cholangiocarcinoma extrahepatic or intrahepatic?
extrahepatic
1 multiple choice option
s/s of extrahepatic cholangiocarcinoma
- constant, dull RUQ ache
- weight loss
- sx of biliary obstruction:
*jaundice
*pruritis
*clay colored stools
*dark urine
s/s of intrahepatic cholangiocarcinoma
- constant, dull RUQ ache
- weight loss
- elevated ALP
- jaundice less likely
how is cholangiocarcinoma diagnosed?
- labs (serum transaminases [AST, ALT, ALP, GGT], bilirubin [total, direct & indirect])
- RUQ ultrasound (US)
- GI referral (MRCP/ERCP)
what finding on RUQ ultrasound is concerning for cholangiocarcinoma?
ductal dilation w/o stones
what is primary sclerosing cholangitis?
autoimmune, fibrous obliteration of intra or extrahepatic bile ducts
- s/s: malaise, fatigue, pruritis
- may be idiopathic or autoimmune
- 50% will also have IBD
- 10-20% will develop cholangiocarcinoma
- tx: transplant
what is primary biliary cholangitis (biliary cirrhosis)?
autoimmune destruction of interlobular bile ducts
- middle aged women
- women > men (15:1)
- insidious onset over decades
- s/s: pruritis, hepatomegaly, abnormal lipid metabolism; + antimitochondrial antibody
does biliary colic have any systemic sx?
no
1 multiple choice option
in general, how is acute cholecystitis treated?
- admit
- broad spectrum abx
- surgical consult
what is charcot's triad associated w/?
ascending cholangitis
- which is a surgical emergency
if GB can be seen on plain xray:
evaluate
- this is NOT normal
which of these is an autoimmune, fibrous obliteration of intra or extrahepatic bile ducts?
a. primary sclerosing cholangitis (PSC)
b. primary biliary cholangitis (PBC)
a. primary sclerosing cholangitis (PSC)
- assoc. w/ IBD & cholangicarcinoma
which of these is an autoimmune destruction of interlobular bile ducts?
a. primary sclerosing cholangitis (PSC)
b. primary biliary cholangitis (PBC)
b. primary biliary cholangitis (PBC)
- will also see a positive (+) antimitochondrial antibody