4. Biliary Disorders

Pathophys of biliary disease

Abnormalities in bile composition, biliary anatomy, or function

Cholelithiasis

Presence of gallstones

Cholecystitis

Inflammation due to acute persistent obstruction of cystic duct

Choledocholithiasis

Stones in common bile duct (blockage of gallbladder and liver bile)

Cholangitis

Inflammation & infection of common bile ducts

Risk factors for cholelithiasis

Women, age, Chrohn, "thrifty" genes (promote fat storage)

"Female, forty, fertile, fluffy"

Demographic associated with "thrifty" genes

Native North and South Americans

S/S of cholelithiasis

Asymptomatic (until obstruction)

Biliary colic - Constant, dull discomfort in RUQ or epigastrium w/ radiation to back; intermittent and transient lasting >30 mins to 6 hours; NO change with movement, gas, BM

Gallstone ileus

Stone passes biliary tree, gets stuck in intestine/ileocecal valve → small bowel obstruction

Management of any history of complications associated with gallstones?

Cholecystectomy

Nonsurgical management options for cholelithiasis (2)

- Oral bile acid dissolution (ursodiol)

- Percutaneous cholecystostomy & gallstone extraction

MCC of acute cholecystitis

Gallstones (especially with history of biliary colic)

MC organisms that cause infection of biliary system in acute cholecystitis

E. coli, enterococcus, enterobacter

S/S of acute cholecystitis

Sustained pain in epigastrium (4-6 hours), radiation to R shoulder, fever, N/V

PE of acute cholecystitis

RUQ/epigastric tenderness, + Murphys, guarding/rebound tenderness, palpable gallbladder

If jaundice is present when considering acute cholecystitis...

Consider choledocholithiasis

Lab workup & findings of acute cholecystitis

CBC → Leukocytosis

LFTs → Elevated total bilirubin and alk phos

Diagnostic imaging & findings of acute cholecystitis

RUQ US → gallstones or sludge in GB; GB wall thickening, pericholecystic fluid, sonographic Murphy's

(can also use HIDA, reliable with bilirubin <5)

Management of acute cholecystitis

NPO, IVF, Analgesics

ABX - 2-3rd gen cephalosporin + metronidazole

Cholecystectomy (laparoscopic)

Management of non-surgical acute cholecystitis

US guided aspiration of GB & cholecystostomy tube

OR

ERCP

Within what time frame should a cholecystectomy be performed for acute cholecystitis

24 hours of hospital admission

Risk factor/demographic for acalculus cholecystitis

Critically ill/major surgery

MC in NPO with multiorgan failure (and also sedated)

Acalculus cholecystitis

Acute necroinflammatory disease of gallbladder → gallbladder stasis and ischemia/gangrene

**HIGH morbidity/mortality

S/S & presentation of acalculus cholecystitis

- Development of fever, leukocytosis, vague abd discomfort

- MC in NPO with multiorgan failure (and also sedated) especially if jaundice is present

Lab workup & findings of acalculus cholecystitis

Blood cultures

LFTs → Elevated

CBC → Leukocytosis w/ significant L shift

Diagnostic imaging & findings of acalculus cholecystitis

US → NO stones/sludge, GB wall thickening, pericholecystic fluid

In ill patients with septic-like presentation and jaundice, what should be considered?

Acalculus cholecystitis

Management of acalculus cholecystitis

Percutaneous cholecystostomy tube + ABX

Presentation of acute choledocholithiasis vs cholangitis

Cholangitis more severe; has CONSTANT pain, fever, jaundice & potential secondary pancreatitis

Pathogenesis of acute cholangitis

Bacterial infection behind biliary obstruction

Charcot's triad

Fever

RUQ pain

Jaundice

**Indicative of acute cholangitis

Reynold's pentad

Fever, RUQ pain, jaundice (Charcot's triad), AND

Shock/sepsis

AMS

**Indicative of acute cholangitis

Diagnostic workup & findings of acute cholangitis

Dilated CBD on US and MRCP (magnetic resonance cholangiopancreatography - evaluates bile ducts)

Management of acute cholangitis (with Charcot's triad)

NPO, IVF, pain

ABX - IV Zosyn (cultures pending)

ERCP with sphincterotomy and stone extraction (biliary drainage)

Management of acute cholangitis with vs without charcot's triad

Without: US → ERCP within 24 hours

With: Stabilize → ERCP for immediate drainage

Management of acute cholangitis with failed/contraindicated ERCP

Percutaneous transheptic cholangiography for stone extraction/stent placement & urgent surgical decompression