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SURGERY

Cholecystitis

QuestionAnswer
complications from gallstone disease gallbladder (acute and chronic cholecystitis); passage of stones (pancreatitis, choledocholithiasis, cholangitis, gallstone ileus)
in gallstone disease, elevated WBC and gallbladder thickening are c/w acute or chronic cholecystitis? both
If biliary colic and nl WBC, gallstones, and no gallbladder thickening, what is treatment? elective lap chole
Tx of acute cholecystitis hospital admission, IVF, NPO, IV abx, lap chole
biliary colic waxing and waning, poorly localized post-prandial upper abdominal pain radiating to the back and nl LFT's.
What causes biliary colic? gallstone obstruction at the neck of the gallbladder or gallbladder dysfunction --> food ingestion --> cholecystokinin-stimulated gallbladder contraction --> pain
acute cholecystitis - what is it caused by? stone blocking cystic duct
how does the gallbladder get infected? blockage --> bacterial infection via the lymphatics
What are the most common organisms that cause infection in cholecystitis? Ecoli, klebsiella, proteus, strep faecalis
sx's of acute cholecystitis? persistent RUQ pain, +/- fever, gallbladder tenderness, leukocytosis, mild, nonspecific elevated LFT's (may indicate common bile duct stones)
acalculous cholecystitis biliary stasis --> gallbladder inflammation --> gallbladder distension, venous congestion, decreased perfusion.
acalculous cholecystits is etiology of what percentage of all cute cholecystitis presentations 5% of acute cholecystitis
what population prone to develop acalculous cholecystitis pts hospitalized with critical illness
chronic cholecystitis repeated bouts of ciliary colic and/or repeated bouts of acute cholecystitis --> gallbladder wall inflammation and fibrosis --> gallbladder wall thickening
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
what is cholangitis infection WITHIN the bile ducts (usu 2/2 obstruction by gallstones or strictures)
Charcot triad RUQ pain, jaundice, fever - seen in cholangitis in 70% of pts; life threatening.
complications of cholangitis sepsis and multiple-organ failure
tx for cholangitis abx and supportive care; for severe, endoscopic decompression of bile duct by ERCP or surgery
What is the gold standard for imaging gallstone disease? RUQ U/S - 98-99% sensitivity in ID gallstones in gallbladder.
How can U/S indicate choledocholithiasis? can measure diameter of bile duct, which can indicate possible presence of stones in common bile duct
choledocholithiasis stones in the common bile duct
How reliable is detecting stones in common bile duct stones in the common bile duct are detected on US <50% of the time
biliary scintigraphy Using IV radiotracer to study gallbladder fxn and biliary patency; first liver --> gallbladder --> duodenum
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
What does ERCP stand for? endoscopic retrograde cholangiopancreatography
Describe ERCP injection of contrast material into common bile duct to visualize the duct
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
what are the two types of gallstones? Which is more common? cholesterol (more common) and pigmented
w/u for gallstone dz H&P, CBC LFT's, serum amylase, RUQ US
pt presents w post-prandial pain <6h duration, afebrile, mild RUQ tenderness. Elevated LFT's and dilation of common bile duct by US. choledocholithiasis
Tx for biliary colic elective lap chole
Tx for choledocholithiasis hospital admission, observation for development of cholangitis, ERCP for stone clearance, cholecystectomy
RUQ US with CBD diameter >5mm in the setting of elevated LFT's choledocholithiasis
RUQ pain with significantly elevated amylase and lipase suspect gallstone pancreatitis
tx for acute and chronic cholecystitis cholecystectomy
Tx for gallstone pancreatitis bowel rest and IV hydration; once pancreatitis resolves --> lap chole
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
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
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
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)
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
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
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
Indications for cholecystectomy in pregnancy 1. cholecystitis, 2. intractable pain, 3. cholangitis
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.
Tx for cholecystitis hospitalization, IV abx, lap chole
persistent abd pain, RUQ tenderness, leukocytosis acute cholecystitis
fever, intermittent RUQ pain, jaundice cholangitis
intermittent abd pain and minimal tenderness over gallbladder biliary colic
epigastric pain and back pain acute pancreatitis
65 yo pt w fever or hypothermia, jaundice, abd pain, shaking chills cholangitis
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.
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.
Things that cause biliary colic mechanical obstruction; gallbladder dysfunction
biliary dyskenesia biliary colic 2/2 gallbladder dysfunction in the absence of gallstones
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.
Created by: christinapham