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Biliary Disease


Biliary labs bilirubin, alk phos, ALT, AST
Cholestatic vs hepatitis: labs cholestasis: bili/alk phos high; hep: ALT/AST high
US: useful to: Detect GS; eval dilation of biliary ducts (limits: obesity; eval liver parenchyma/panc)
CT & MRI X-section imaging of entire abd; eval liver parenchyma; MRI ID’s stones well; BUT: Cost; May miss stones;Radiation
EUS useful in: large pt
HIDA Delayed visualization in pts with liver dz, choledocholithiasis (accelerated by IV morphine); false pos in ill pts & fasting; also used for cystic duct leaks & biliary dyskinesia
Cholesterol stones: GB; Large, yellow
Black pigment stones: GB; Calcium bilirubinate; in pts with cirrhosis and chronic hemolysis (eg, sickle cell)
Brown pigment stones: Ducts; Calcium salt of unconjugated bilirubin; assoc w/ infection; Form denovo in the ducts
Gold standard for GS US; sensitivity > 95% for stones > 2mm (less sensitive for stones in CBD); GS best seen after 8hrs of fast; Stones seen as echogenic, mobile objects with acoustic shadow
Most common stone locations 75% GB (Asx); cystic duct (20% intermittent: biliary colic; 10% impacted: cholecystitis)
Cholangitis Stone in CBD; bile stasis, infection, bacteremia; Charcot’s triad/ Reynold’s Pentad; high WBC; Bili, ALP; pos blood cx; Emergent ERCP / PTC w/ Abx; Subsequent cholecystectomy
Charcot’s triad: Pain, Fever, Jaundice
Reynold’s Pentad: Charcot’s triad plus hypotension and mental confusion; suggests sepsis
Most effective procedure for detecting and removing cholangitis stones ERCP; appear as filling defects; high rate of complications
Choledocholithiasis Causes intermittent obstruction of CBD; indistinguishable from biliary pain; Predisposes to cholangitis and pancreatitis;
Choledocholithiasis: findings Pain with jaundice; Elevated ALP, bili; ERCP / MRI / EUS / US
Choledocholithiasis: Tx ERCP with stone removal and early lap cholecystectomy
EUS: Highly accurate for CBD stones; invasive / expensive; No risk of pancreatitis compared to ERCP
Panc ca: most common sx Pain, obstructive jaundice, weight loss; BUT classic hx = painless jaundice
Panc ca: RFs smoking, chronic pancreatitis, obesity and family history; 5 year survival of 5%
Diffuse intra- and extrahepatic bile duct inflammation and fibrosis: PSC
PSC: assoc with: UC (most cases); leads to cirrhosis and portal HTN; elev alk phos, pruritus, fatigue; Cholangitis
Organisms complicating cholecystitis (found in GB or CBD: E Coli (41%), Enterococcus (12%), Klebsiella (11%), Enterobacter (9%), B fragilis, Pseudomonas
Mirizzi syndrome = a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
Cholecystitis abx: Augmentin (2G TID), Zosyn, Rocephin + Flagyl, OR Levaquin + Flagyl
Created by: Adam Barnard Adam Barnard