Disorders of Biliary Tract

what is cholelithiasis?

gallstones

T/F: 8% of men experience gallstones while 17% of women experience them

true

risk factors for cholelithiaisis

female, obese, middle age, pregnancy, high dietary fat consumption, oral contraceptive use, rapid weight loss

what is another name for gallbadder stones?

calculi

what are gallstones usually composed of?

cholesterol

what makes gall stones occur (from cholesterol)?

increased biliary secretion of cholesterol, cholesterol solubility in bile exceeded

what is the precursor to gallstones called?

sludge

T/F: gallstones can be caused by large or small sludge

true

along with cholesterol, what also plays a role in cholelithiasis

gall bladder motility/contraction

how can gall bladder motility/contraction play a role in cholelithiasis?

it continues to increase the concentration of bile which leads to increased likelihood of stone formation

how to diagnose cholelithiasis

abdominal ultrasound, CT, ERCP, HIDA scan

T/F: stones in gallbladder can be asymptomatic & found on routine imaging

true

if there is migration into cystic duct or CBD (biliary colic) what symptoms occur

severe, steady ache in RUQ or epigastric region that can radiate into the scapula and shoulder

complications of gall stones

choledocholithiasis, cholecystitis, cholangitis

what does choledocholithiasis mean

migration of gallstones into cystic duct or common bile duct

treatment of cholelithiasis

cholecystectomy (laparoscopic) can do open also, ERCP (endoscopic retrograde cholangiopancreatography)

define cholecystitis

inflammation of the gallbladder - can be acute or chronic

what is acute cholecystitis

usually the result of obstruction from a stone, increased pressure within the gallbladder leads to distention and ischemia within gallbladder mucosa and wall

T/F: there is release of local inflammatory tissue factors and bacterial inflammation in acute cholecystitis

true

what is acalculous cholecystitis

inflammation of the gallbladder without gallstones

how many patients with cholecystitis experience calculous cholecystitis

5-10%

T/F: >50% of calculous cholecystitis cases have no cause found

true

what may be responsible for acalculous cholecystitis

biliary sludge

when is calculous cholecystitis more common seen

in burn/trauma, postpartum after prolonged labor, or prolonged TPN use

symptoms of acute cholecystitis

typically starts with biliary colic that doesn’t remit and progressively gets worse, N/V, not eating, ± fever

how is acute cholecystitis diagnosed

clinically (physical exam findings, RUQ tender to palpation), labs (WBCs, bilirubin, and alkaline phosphatase), vitals (fever), ultrasound, ERCP, HIDA (hepatobiliary iminodiacetic acid scan)

treatment of acute cholecystitis

bowel rest (IV fluids), antibiotics if indicated, pain medications, cholecystectomy

what is chronic cholecystitis

chronic inflammation of gallbladder that is almost always associated with gallstones - can be repeated acute cholecystitis episodes

facts regarding chronic cholecystitis

bacterial may be present in the bile, pts can be asymptomatic for years, can present with acute cholecystitis after being chronic, and can present with a complication

complications of cholecystitis

empyema, hydrops, gangrene, jaundice, perforation, fistula formation

what is jaundice

physical manifestation of hyperbilirubinemia

normal lab value for total bilirubin

<1.2 mg/dL

normal lab value for conjugated bilirubin

<0.2 mg/dL

normal lab value for unconjugated bilirubin

< 1.0 mg/dL

what causes unconjugated hyperbilirubinemia?

increased bilirubin productions (increased RBC breakdown), impaired bilirubin transport into hepatocytes preventing conjugation, and defective conjugation within the hepatocytes

what causes conjugated hyperbilirubinemia?

impaired transport from hepatocyte to biliary duct, extrahepatic obstruction resulting in buildup of bilirubin in hepatocytes causing backward leakage into the blood

T/F: excess bilirubin can deposit in the skin and sclera

true

where is bilirubin filtered?

in the kidney - excess will spill into urine

define cholangitis

inflammation of the bile ducts

what are the types of cholangitis?

ascending cholangitis or acute cholangitis, primary sclerosing cholangitis

what is ascending cholangitis

an acute infection in the biliary tract usually from biliary stasis/obstruction

what can occur in ascending cholangitis?

bacteria can migrate upwards from the duodenum and normal defense mechanisms are disrupted (sweeping action of bile, sphincter of Oddi, biliary duct permeability)

symptoms of ascending cholangitis

Charcot’s triad - fever, abdominal pain, jaundice

complications of ascending cholangitis

sepsis, bacteremia, septic shock, death

how is ascending cholangitis diagnosed

clinical picture (Charcot’s triad), elevated WBC (neutrophils), elevated ALP/GGT/bilirubin, ultrasound (evaluate for dilatation or stones)

how to treat ascending cholangitis with ERCP

stone removal, stenting of bile duct (to allow for biliary drainage)

which bacteria are seen in ascending cholangitis infections

enteric gram negatives/strep/enterococcus, anaerobes

how to treat infection in ascending cholangitis

ampicillin/sulbactam, piperacillin/tazobactam, ceftriaxone + metronidazole, ciprofloxacin + metronidazole

how treat sepsis ± shock associated with ascending cholangitis

fluids and pressors

why would a cholecystectomy be done for ascending cholangitis?

to prevent recurrence