Cholecystitis
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| complications from gallstone disease | gallbladder (acute and chronic cholecystitis); passage of stones (pancreatitis, choledocholithiasis, cholangitis, gallstone ileus)
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| in gallstone disease, elevated WBC and gallbladder thickening are c/w acute or chronic cholecystitis? | both
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| If biliary colic and nl WBC, gallstones, and no gallbladder thickening, what is treatment? | elective lap chole
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| Tx of acute cholecystitis | hospital admission, IVF, NPO, IV abx, lap chole
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| biliary colic | waxing and waning, poorly localized post-prandial upper abdominal pain radiating to the back and nl LFT's.
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| What causes biliary colic? | gallstone obstruction at the neck of the gallbladder or gallbladder dysfunction --> food ingestion --> cholecystokinin-stimulated gallbladder contraction --> pain
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| acute cholecystitis - what is it caused by? | stone blocking cystic duct
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| how does the gallbladder get infected? | blockage --> bacterial infection via the lymphatics
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| What are the most common organisms that cause infection in cholecystitis? | Ecoli, klebsiella, proteus, strep faecalis
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| sx's of acute cholecystitis? | persistent RUQ pain, +/- fever, gallbladder tenderness, leukocytosis, mild, nonspecific elevated LFT's (may indicate common bile duct stones)
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| acalculous cholecystitis | biliary stasis --> gallbladder inflammation --> gallbladder distension, venous congestion, decreased perfusion.
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| acalculous cholecystits is etiology of what percentage of all cute cholecystitis presentations | 5% of acute cholecystitis
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| what population prone to develop acalculous cholecystitis | pts hospitalized with critical illness
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| chronic cholecystitis | repeated bouts of ciliary colic and/or repeated bouts of acute cholecystitis --> gallbladder wall inflammation and fibrosis --> gallbladder wall thickening
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| what sx's does pt with chronic cholecystitis present with? What are the US findings? | persistent/recurrent localized RUQ pain without fever or leukocytosis; US - thickened gallbladder wall or contracted gallbladder
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| what is cholangitis | infection WITHIN the bile ducts (usu 2/2 obstruction by gallstones or strictures)
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| Charcot triad | RUQ pain, jaundice, fever - seen in cholangitis in 70% of pts; life threatening.
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| complications of cholangitis | sepsis and multiple-organ failure
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| tx for cholangitis | abx and supportive care; for severe, endoscopic decompression of bile duct by ERCP or surgery
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| What is the gold standard for imaging gallstone disease? | RUQ U/S - 98-99% sensitivity in ID gallstones in gallbladder.
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| How can U/S indicate choledocholithiasis? | can measure diameter of bile duct, which can indicate possible presence of stones in common bile duct
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| choledocholithiasis | stones in the common bile duct
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| How reliable is detecting stones in common bile duct | stones in the common bile duct are detected on US <50% of the time
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| biliary scintigraphy | Using IV radiotracer to study gallbladder fxn and biliary patency; first liver --> gallbladder --> duodenum
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| What does it mean if you don't see the gallbladder in biliary scintigraphy in pt with RUQ pain? | gallbladder dysfxn caused by acute or chronic cholecystitis
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| What does ERCP stand for? | endoscopic retrograde cholangiopancreatography
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| Describe ERCP | injection of contrast material into common bile duct to visualize the duct
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| describe what you can do therpeutically in ERCP | endoscopic sphincterotomy in duodenum --> facilitates bile drainage and clearance of stones in bile duct --> tx cholangitis and choledocholithiasis
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| what are the two types of gallstones? Which is more common? | cholesterol (more common) and pigmented
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| w/u for gallstone dz | H&P, CBC LFT's, serum amylase, RUQ US
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| pt presents w post-prandial pain <6h duration, afebrile, mild RUQ tenderness. Elevated LFT's and dilation of common bile duct by US. | choledocholithiasis
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| Tx for biliary colic | elective lap chole
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| Tx for choledocholithiasis | hospital admission, observation for development of cholangitis, ERCP for stone clearance, cholecystectomy
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| RUQ US with CBD diameter >5mm in the setting of elevated LFT's | choledocholithiasis
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| RUQ pain with significantly elevated amylase and lipase | suspect gallstone pancreatitis
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| tx for acute and chronic cholecystitis | cholecystectomy
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| Tx for gallstone pancreatitis | bowel rest and IV hydration; once pancreatitis resolves --> lap chole
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| When should a pt with uncomplicated biliary pancreatitis undergo cholecystectomy? Why? | same hospitalization; when chole is delayed, 25-30% of pts may develop recurrent bouts of pancreatitis within a 6-wk period
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| Sx's of biliary colic; exam; US; Lab studies | postprandial pain <6h; afebrile, mild tenderness over gallbladder; US gallstones in gallbladder, but NO wall thickening and NO CBD dilation; Lab nl WBC, LFT, amylase
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| Sx's of acute cholecystitis; exam; US; Lab studies | Persistent epigastric or RUQ pain >8h; either afebrile or febrile, usu localized gallbladder tenderness; gallstones, pericholecystic fluid, +/- CBD dilation; nl or elevated WBC, nl or mildly elevated LFT's
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| Sx's of chronic cholecystitis; exam; US; Lab studies | Persistent recurrent RUQ pain; afebrile, +/- localized tenderness over a palpable gallbladder; gallstones, thickened wall, +/- contracted gallbladder (advanced)
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| Sx's of choledocholithiasis; exam; US; Lab studies | postprandial abd pain that improves with fasting; +/- jaundice, nonspecific RUQ abd tenderness; gallstones, CBD usu dilated; elevated LFT's - dependent on complete or partial obstruction
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| Sx's of biliary pancreatitis; exam; US; Lab studies | persistent epigastric and back pain; epigastric tenderness to deep palpation; gallstones, CBD dilation MAY occur 2/2 pancreatitis; inc WBC, inc amylase >1000, LFT elevation may be transient, but persistent LFT's indicate CBD stones
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| 65 yo woman, post prandial RUQ pain, N/V x 12h; Pain is persistent and radiates to the back; afebrile, tender in RUQ; US shows gallstones, wall thickening, 12mm CBD; elevated WBC, AST/ALT, AlkPhos, tBili. What does she have? What is tx? | cholangitis; admit to hospital, IVF, IV abx, ERCP
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| Indications for cholecystectomy in pregnancy | 1. cholecystitis, 2. intractable pain, 3. cholangitis
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| Indications for cholecystectomy | 1. clear link between pt sx's and gallstones OR 2. objective evidence of gallbladder dysfxn (i.e. US w thickened gallbladder wall, no gallbladder on biliary scintigraphy) or 3. gall-stone related complications.
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| Tx for cholecystitis | hospitalization, IV abx, lap chole
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| persistent abd pain, RUQ tenderness, leukocytosis | acute cholecystitis
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| fever, intermittent RUQ pain, jaundice | cholangitis
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| intermittent abd pain and minimal tenderness over gallbladder | biliary colic
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| epigastric pain and back pain | acute pancreatitis
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| 65 yo pt w fever or hypothermia, jaundice, abd pain, shaking chills | cholangitis
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| If pt with gallstone dz shows signs of infection, should cholecystectomy be done right away or be delayed? | Early. Early operative tx did not contribute to increase in operative complications; early surg resulted in reduction of hospital stay and readmissions.
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| 30yo woman w postprandial upper abd pain, recurrent. No gallstones. Nl LFT's. What is the next step? | Sx's of biliary colic - most commonly caused by mechanical obstruction, but can also be by gallbladder dysfxn.
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| Things that cause biliary colic | mechanical obstruction; gallbladder dysfunction
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| biliary dyskenesia | biliary colic 2/2 gallbladder dysfunction in the absence of gallstones
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| How to diagnose biliary dyskenesia? | HIDA scan following CCK administration. Nl: CCK injection --> gallbladder contracts --> 50% ejection fraction. BDyskenesia:lower ejection fraction + reproduction of sx's with injection.
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