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Bile
Bile
Bile pigments (bilirubin & biliverdin) + cholesterol + phospholipids, ions, amino acids ➔ bile acid
Primary bile acids are produced in liver and stored in gallbladder
Secondary bile acids are produced in intestine by bx
Fat absorption (and fat soluble vitamins)
Cholesterol and bilirubin excretion
Gall Stones
Gall Stones
Cholesterol stones (MC)
Excess cholesterol or ↓ bile secretion
Female, Fat, Fertile, Forty, Fibrates, Family hx
Pregnancy (↑progesterone) ➔ ↓ gallbladder contraction ➔ stasis
Mostly radiolucent
Black pigment stones
Hemolytic anemia ➔ ↑ bilirubin
Radiolucent
Brown (mixed) pigment stones
Biliary infxn ➔ bilirubin and bile breakdown
Radiopaque
Cholelithiasis
Cholelithiasis
Calculous (MC) - gallstone obstruction in cystic duct
SSX - Usually incidental finding or ASX
Biliary colic - dull but intense RUQ discomfort that stops after ~ 6hrs
Biliary colic is not colicky... it's constant
Boas sign - Irritated phrenic nerve ➔ referred right shoulder blade pain
Belching, nausea, fullness (especially after high fat food)
TX
Avoid HFF, elective cholecystectomy
Acute Cholecystitis
Acute Cholecystitis
Calculous (MC) - gallstone obstruction in cystic duct ➔ infection (MC E. coli, or other Gram NEG)
Acute cholecystitis ➔ chronic cholecystitis - calcification (radiopaque) ➔ porcelain GB , ↑↑ RF for GB cancer
Acalculous - really sick inpt ➔ NPO ➔ GB stasis ➔ inflammation & distention ➔ infxn
Emphysematous - infxn with Clostridium or other gas forming bx ➔ air in GB wall
SSX
RUQ pain (especially after HFF) ± radiation to right scapula (Boas sign)
Fever & ↑ WBC
Positive Murphy sign: Deep palpation of RUQ during inspiration ➔ ↑ pain & cessation of inspiration
DX
RUQ US first, shows distended GB with double-wall (edema hyperechoic inner and outter wall, hypoechoic in between)
HIDA scan (gold standard) Hepato-imino-diacetic Acid Scintigraphy
Within 4 hours (or 30 min with morphine)
Radiotracer should be visualized in normal GB within 30 mins - 4 hours
Morphine ➔ ↑ sphincter of Oddi pressure ➔ more tracer entering GB quicker
TX
NPO & empiric ABX (metronidazole and cephalosporin)
Cholecystectomy (laparoscopic > open; open if hx of ABD surgeries)
Cholecystostomy (percutaneous drainage) if too sick for surgery
Choledocholithiasis
Choledocholithiasis
Primary: stones formed in common bile duct
Secondary (MC): GB stone ➔ common bile duct obstruction ➔ stasis of biliary tract
Complication 2-3yrs s/p cholecystectomy
SSX
RUQ pain/tenderness, N/V
± Jaundice & enlarged GB (Courvoisier's sign) MC in neoplasm blocking CBD
DX/TX
Obstruction ➔ ↑ ALP, ↑ GGT, ↑AST/ALT, ↑ bilirubin
RUQ US first
MRCP (magnetic resonance cholangiopancreatography) low-int risk
ERCP (endoscopic retrograde cholangiopancreatography) with stone removal
Cholecystectomy if GB dz
Cholangitis
Cholangitis
Choledocholithiasis ➔ infection (MC E. coli, or other Gram NEG)
Can be from other obstruction (acute pancreatitis, PSC, post-ERCP)
SSX
Charcot triad: RUQ pain, fever (↑ WBC) , jaundice
Reynold's pentad: add AMS and hypotension
DX
Obstruction ➔ ↑ ALP, ↑ GGT, ↑AST/ALT, ↑ bilirubin, ↑ CRP
RUQ US first, shows dilated CBD and thick bile duct walls
CT with IV contrast or MRCP if US inconclusive
TX
Get blood cultures then empiric ABX (metronidazole and cephalosporin)
Biliary drainage within 24hrs
ERCP guided trans-papillary biliary drainage with sphincterotomy or stent
Don't have to wait for afebrile
Percutaneous transhepatic biliary drainage
Open choledochotomy with T-tube drains if ERCP fails
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