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