Diseases of the Gallbladder and Biliary Tract

What are the 3 causes of acute cholecystitis?

1. stones obstructing neck of gallbladder or the cystic duct (MC) 2. Calculus cholecystitis 3. parasitic worms

juandice is indicated in a total bilirubin measurement over:

2.5

Normal thickness of GB wall

3mm

This list describes which diagnostic criteria? 1. pericholecystic fluid collection 2. gallbladder wall thickening >3mm 3. gallbladder distension 4. +/- dilation of proximal CBD

4 minor US acute cholecystitis dx criteria

Normal diameter of proximal CBD

5-6 mm <10mm

What is the normal biliary ejection fraction?

>50%

Describe the flow of bile from the liver to duodenum

Bile flows out of the liver through the left and right hepatic ducts, which come together to form the common hepatic duct. This duct then joins with a duct connected to the gallbladder, called the cystic duct, to form the common bile duct. The pancreatic duct joins the common bile duct in the ampulla of Vater. This then enters the small intestine at the sphincter of Oddi (a ring-shaped muscle), located a few inches below the stomach.

The liver has >500 functions. What are the 6 that were highlighted in lecture?

Digestion, Metabolism, Detoxification, Production, Storage, Immunity

PT/INR is sensitive to what clotting factors?

II, V, VII, X

Treatment of Ascending cholangitis?

IVF, abx, analgesics, ERCP, then cholecystectomy

Treatment of Choledocholithiasis?

IVF, abx, analgesics, ERCP, then cholecystectomy

Treatment of Acute cholecystitis?

IVF, abx, analgesics, then cholecystectomy

After administration of CCK, the flow of bile into the duodenum followed by radioisotope scan should normally empty in what amount of time?

Less than 2 hours

This is an MRI that visualizes the entire gallbladder, biliary tree, and pancreatic duct. non-invasive

MRCP

This test is a good alternative for patients with renal complications or allergy to iodinated contrast. non-invasive

MRCP

Which can we both diagnosis and treat with vs. which can we only diagnose with? MRCP or ERCP?

MRCP = diagnose only ERCP= diagnosis and TrEEt (treat :)

Treatment of Acalculus cholecystitis?

Stabilize, decompress with T tube, then emergency cholecystectomy

Which do we start with in biliary testing? MRCP or ERCP?

Start with MRCP!

(Supersaturate w/ cholesterol or biliary stasis?) Increase in age, increase in estrogen, ethnicity, rapid wt loss, IBD, metabolic changes

Supersaturate bile with cholesterol

Best diagnostic test: cholelithiasis

US

Best diagnostic test: Acalculus cholecystitis

US will show negative stones but + gallbladder distention, Perichole fluid, thick wall) HIDA is dx test of choice

Best diagnostic test: Acute Cholecystitis

US, then HIDA or CT as needed

Best diagnostic test: Ascending Cholangitis

US: may show CBD dilation. ERCP test of choice

Best diagnostic test: Choledocholithiasis

US; may show CBD dilation MRCP or EUS test of choice

Symptomatic gallstone disease

biliary colic

This is a functional motility disorder with RUQ pain (~30min) in the absence of obvious gallbladder pathology. Pain may be associated with N/V and will interrupt normal daily activities.

biliary dyskinesia

What does a biliary ejection fraction of less than 30-35% indicate?

biliary dyskinesia

These stones are made from an increase in bilirubin breakdown such as in hemolysis, sickle cells, splenomegaly

black stones

These stones are made from infection

brown stones

this is a gallstone traveling in or blocking the common bile duct

choledocholitiasis

gallstones in the bladder aka

cholelithiasis

An increase in ALP increases the risk that the source is from

cholestasis

If ALP, GGT, T bili is greater than AST, ALT =

cholestasis

In this primary issue, the complications can increase the risk of gallbladder carcinoma if the gallbladder is not removed

chronic cholecystitis

unconjugated or conjugated? Biliary epithelial and hepatocyte damage

conjugated

unconjugated or conjugated? Intrahepatic cholestasis

conjugated

A ____ bilirubin test can further tell us where the bilirubin increase is coming from

fractionation

(supersaturate w/ cholesterol or biliary stasis?) TPN, prolonged fasting, keto diet, DM

increase biliary stasis

This = byproduct of heme breakdown excreted into bile by the liver

indirect (unconjugated) bilirubin direct (conjugated) bilirubin

This test is used to help the surgeon to identify stones from the liver to the small intestine to help reduce accidents in surgery. A small catheter is placed in the cystic duct which drains bile from the gall bladder to the CBD. X Rays are then taken, looking for stones in CBD.

intraoperative cholangiogram (IOC)

(lap/open cholecystectomy) -same day procedure -OR time: 45 min-2 hours -back to work 1 week

laparoscopic cholecystectomy

Cholecystectomy in a patient without sx is (more/less) likely to result in clinical improvement

less

Sludge is a ____ finding

non-specific

Treatment of cholelithiasis?

none if asx or elective cholecystectomy

(lap/open cholecystectomy) -home in 1-2 days -OR time: 1.5-2.5 hrs -back to work 2-4 weeks

open cholecystectomy

This is a rare, full thickness calcification of the gallbladder wall, a bluish tint and brittle consistency of wall that is noted during gallbladder removal surgery. Increases the risk of gall bladder carcinoma

porcelain gallbladder

Pre-hepatic, hepatic, or post-hepatic? seen in biliary obstruction like with gallstones or tumors

post-hepatic

Pre-hepatic, hepatic, or post-hepatic? seen with hemolysis like in transfusion reactions & sickle cell anemia

pre-hepatic

Maximal tenderness over the gallbladder with an ultrasound probe is an example of

+ sonographic Murphy's sign

What are 3 potential complications of ERCP?

-iatrogenic pancreatitis -perforation -bile peritonitis

What are the cons to gallbladder US?

-stones outside the GB can be missed -stones <2-3 mm may be missed

Diagnosis of acute cholecystitis requires __ major + __ minor criteria

1 major + 2 minor criteria

If an elderly patient or immunocompromised patient presents with acute cholecystitis, what is the best tx plan?

1. Admit 2. Broad spectrum + anaerobe coverage abx 3. Meperidine for pain, IVF 4. Emergent or delayed lap cholecystectomy

The HIDA scan can check two things. What are they?

1. Is the gallbladder blocked or static? 2. Is the gallbladder emptying correctly?

What are the 2 major US acute cholecystitis dx criteria?

1. Presence of gallstones 2. + sonographic Murphy's sign

What are some of the vitamins mentioned that are stored by the liver?

A, D, E, K and vitamin B12

Remember that GGT helps us isolate the ___ increase to the biliary system

ALP

This test is used for hepatocyte/billiary tract compression from decreased bile flow

ALP, GGT

This test indicates direct hepatocyte injury/death. Note: only assesses over the last 1-2 days

AST, ALT

Bile stasis from dehydration/TPN, severe illness causing gallbladder inflammation

Acalculus cholecystitis

This indicates that the gallbladder is not contracting or relaxing and is diagnosed via HIDA scan.

Acalculus cholecystitis

This variety of cholecystitis is associated with increased morbidity and mortality

Acalculus cholecystitis

Charcot's Triad is used for the diagnosis of

Acute (ascending) cholangitis

This indicates that the gallbladder has a cystic duct obstruction and is diagnosed with a HIDA scan.

Cholecystitis

Predominantly (conjugated/unconjugated) hyperbilirubinemia: Drugs, sepsis, hereditary hepatocanalicular transport defects, extra hepatic biliary obstruction, hepatocellular disease

Conjugated

4 ingredients in bile

Conjugated bilirubin + cholesterol + calcium + bile salts

The majority of gallstones (cause harm/do nothing)

Do nothing!!

These are the "true" liver function tests

PT/INR albumin

Some of the functions of this test/treatment include: -dilating steosed ducts and removing their stones -sphincterotomy -biopsy -stent placement

ERCP

This is retrograde endoscopic imaging of the biliary & pancreatic ducts

ERCP

What are the demographics for biliary dyskinesia?

F>M, <30yo, Caucasian

What are the 5 Fs of gallstone risk factors?

Fair, Fat, Fertile, Forty, Fasting

For biliary issues, add what to the hepatic function panel?

GGT

An impaired conduction of bilirubin by glucuronide is a description of what?

Gilbert syndrome

Cholescintigraphy

HIDA scan (hepatobiliary iminodiacetic acid)

What do these factors do? fasting state, lack of duodenal CCK stimulation, lack of gallbladder use

Increase biliary stasis

What are the name of the immunity cells in the liver that capture/digest worn out cells and debris?

Kupffer cells

Can we use Morphine for pain in a patient with acute cholecystitis?

No! It can cause sphincter of Oddi spasms

Are GGT, PT/INR included in a hepatic function panel?

No! Order them additionally if warranted.

All you see is sludge on your gallbladder US. What's next?

Order a HIDA scan

For liver issues, add what to the hepatic function panel?

PT/INR

Describe a positive Murphy's test

Positive if patient halts during inspiration and complains of RUQ pain

Unconjugated: Pre-hepatic, hepatic, or post-hepatic?

Pre-hepatic and hepatic

Where does gallbladder pain refer to?

Right shoulder or tip of right scapula (viscerosomatic)

In a HIDA scan, what is a normal finding of the radioisotope tracer?

Should be seen in GB within 30 minutes

T/F: elderly & immunocompromised pts do not tend to present with symptoms of acute cholecystitis

True!

gallstone blocking the neck of the gallbladder or cystic duct causing gallbladder inflammation or infection

acute cholecystitis

The blockage of the common bile duct + polymicrobial infection

ascending cholangitis

First line in biliary testing

gallbladder ultrasound

Which test are we going to choose to view the following: -gallstones -Murphy's sign visualization -thickness of GB wall -peri-cholecystic fluid collection -diameter of proximal CBD -presence of sludge

gallbladder ultrasound!

Which has greater concentration? gallbladder bile or liver bile

gallbladder!

Unconjugated hyperbilirubinemia may result from

hemolysis impaired hepatic uptake from certain drugs Gilbert syndrome

Conjugated: Pre-hepatic, hepatic, or post-hepatic?

hepatic (predominantly) and post-hepatic

Both hepatic and non-hepatic disorders may result in:

hyperbilirubinemia

This is collection of calcium carbonate granules and cholesterol crystals

sludge

In a gallbladder US, what can differentiate stones from polyps?

stones are mobile

unconjugated or conjugated? impaired bilirubin uptake or storage

unconjugated

When does the pain occur from gallbladder origin?

up to 2 hours after a fatty meal and lasts <3 hrs

The intestine helps convert bilirubin too ____. This is what gives the brown color to feces

urobilinogen

This makes up 90% of gallstones and are made from cholesterol

yellow stones