Gastroenterology And Biliary Tract Disease Chapter 27 Paauw

Front 1

What are causes of biliary tract disease?

Back 1

Blockage of bile ducts leads to cholecystitis or cholangitis.

Blockage is usually due to gallstones, but rarely is caused by cholangiocarcinoma, primary sclerosing cholangitis, or extrinsic compression by tumor or adenopathy.

Front 2

What is cholecystitis?

Back 2

Inflammation or infection of the gallbladder from obstruction of the cystic duct, usually by a gallstone.

Front 3

What is cholangitis?

Back 3

Cholangitis is a deadly infection arising in the common bile duct due to ductal obstruction. The gallbladder is usually uninvolved.

Front 4

What is primary sclerosing cholangitis (PSC)?

Back 4

PSC causes inflammation and scarring from unclear cause. PSC leaves the biliary ducts thickened and irregularly narrowed and eventually causes cirrhosis and hepatic failure.

Front 5

Patients with what disease are at risk for PSC?

Back 5

Ulcerative colitis.

Front 6

What are the risk factors for gallstones (cholecystitis)?

Back 6

The classic patients with gallstones is "fat, fertile, forty and female", a derogatory but accurate characterization of the risk factors.

Front 7

How does cystic duct occlusion (cholecystitis) present?

Back 7

Cystic duct occlusion occurs as postprandial right upper quadrant pain, worse with fatty food ingestion, as much as 3-4 hours after eating. It commonly occurs at night between 10pm and 2am. It can be intermittent or progressive.

If blockage persists, pain becomes steady, often radiating to the right shoulder. High fever is rare.

Front 8

How does cholangitis present?

Back 8

Cholangitis is a gastrointestinal emergency. The patient presents with a triad of high spiking fevers with rigors, jaundice, and right upper quadrant pain.

Note: If tumor is obstructing the common bile duct, painless jaundice may develop gradually over weeks prior to onset of infection.

Front 9

What are the key features of cholangitis?

Back 9

1. Fevers with rigors
2. Jaundice
3. RUQ pain

Front 10

What does the urine and stool look like in cholangitis?

Back 10

When bile flow to the intestine is completely obstructed, urine is dark (bilirubinuria) and stools are light.

Front 11

More than 30% of patients with cholangitis have concomitant ______.

Back 11

More than 30% of patients with cholangitis have concomitant PANCREATITIS, with pain radiating to the back.

Front 12

What are the key features of primary sclerosing cholangitis?

Back 12

With PSC, patients have intermittent flares of jaundice, pruritus, RUQ pain and sometimes frank cholangitis.

Front 13

What do I look for on a physical exam to indicate cholecystitis or cholangitis?

Back 13

For both cholecystitis and cholangitis:

1. Fever
2. Tachycardia
3. Hypotension
4. RUQ pain
5. Guarding

Peritoneal signs are usually absent.

Jaundice is a feature of cholangitis, but is absent in cholecystitis.

50% of patients with cholecystitis have a palpably enlarged gallbladder.

Front 14

The classic exam finding for cholecystitis is Murphy's sign. How do you elicit it?

Back 14

Palpate the liver edge deeply at the midclavicular line and ask the patient to inhale. When the inflamed gallbadder meets the hand, the patient abruptly stops breathing in. Unfortunately, sensitivty and specificity are low for this maneuver.

Front 15

What labs and studies should I order?

Back 15

When either cholecystitis or cholangitis is suspected, order:

1. CBC
2. Blood cultures
3. Liver function tests
4. Amylase
5. Imaging

Front 16

The hallmarks of ductal blockage in lab tests are:
1.
2.
3.

Back 16

1. elevated alkaline phosphatase
2. elevated GGT
3. elevated bilirubin

Front 17

What should you see on CT if you suspect cholecystitis or cholangitis?

Back 17

Cholecystitis: You may see a thickened, edematous gallbladder wall on ultrasound or CT.

Cholangitis: You may see common bile duct dilation.

If cholecystitis is suspected, but ultrasound is normal, a HIDA scan can confirm cholecystitis by absence of tracer uptake in the gallbladder.

Front 18

What is a HIDA scan?

Back 18

A hepatobiliary iminodiacetic acid (HIDA) scan helps evaluate the function of the gallbladder and the bile ducts. Doctors may also refer to this procedure as cholescintigraphy.

In this procedure, a radioactive tracer is injected into your vein. The tracer travels to your liver and then into the bile ducts. A special scanner placed over your abdomen tracks the movement of the tracer through your biliary tract and makes images of the liver, gallbladder and bile ducts.

A HIDA scan is used to diagnose:

* Obstruction of the bile ducts, such as due to gallstones or rarely, tumors
* Diseases of the gallbladder
* Bile leaks

Front 19

ERCP confirms PSC by the _________ apppearance of bile ducts.

Back 19

beaded appearance of bile ducts

Front 20

What is ERCP?

Back 20

ERCP: Endoscopic retrograde cholangiopancreatography

ERCP is used primarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP combines the use of x rays and an endoscope, which is a long, flexible, lighted tube. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x rays.

Front 21

ERCP confirms cholangiocarcinoma by _________.

Back 21

biopsy: yes, you can take tissue samples during an ERCP.

Front 22

What treatment steps are appropriate for patients with cholecystitis or cholangitis?

Back 22

1. For cholecystitis or cholangitis, start broad-spectrum IV antibiotics to cover gram-negative enterics, gram-positives (Clostridium, enterococcus) and anaerobes (Bacteroides).

2. Volume resuscitate as needed.

3. Patients with cholecystitis may respond to antibiotics alone and warrant elective cholecystectomy.

Front 23

T or F: Asymptomatic patients with gallstones do not require their removal.

Back 23

True

Front 24

Worsening ______ or _________ does warrant urgent cholecystectomy.

Back 24

Worsening FEVER or LEUKOCYTOSIS does warrant urgent cholecystectomy.

Front 25

For cholangitis, consult GI immediately for emergent ERCP with sphinceterotomy to ___________.

Back 25

To decompress the common bile duct.

Front 26

At least _______% of cholecystitis require urgent surgery.

Back 26

25%`

Front 27

What are the complications of cholecystitis?

Back 27

1. empyema
2. gangrene
3. gallbladder perforation with a mortality of 30%

Front 28

T or F: Cholangitis is fatal if untreated.

Back 28

True