Gall Bladder Disorders

Abdominal Pain

• Think anatomically if visceral pain (vs. neuropathic vs. somatic)
  
  • Obstruction is colicky, restless
    
  • Inflammatory is constant fever, WBC
    
  • Perforation is high fever, WBC, motionless
    
  • Ischemia is pain out of proportion, bloody poop
    
• RUQ and GU = US
  
• All other areas = CT

Abdominal Pain Differentials

Gallbladder

• a small pouch that sits just under the liver.
• stores bile produced by the liver.
• Gallbladder disease includes inflammation, infection, stones or blockage of the gallbladder. 

Biliary Colic

• Presentation:
  • RUQ pain
  • N/V

• ---

  Diagnosis:
  • LFTs mildly elevated
  • US – Gallstones

• ---

  Treatment:
  • Analgesia
  • Lifestyle advice
  • Lap Chole

Cholelithiasis

• Def:
  • the presence of gallstones in the gallbladder

• ---

  Risk Factors:
  • Fat
    
  • Forty
    
  • Female
    
  • Fertile
    
  • Native Americans (higher incidence of diabetes and obesity)
  • -high cholesterol
    
  • -age >40; menopause
    
  • -losing weight too quickly
    
  • -genetics
    
  • -diabetic

• ---

  Presentation:
  • Colicky RUQ pain radiates to the shoulder
    worse with fatty foods
  • •Pain after high fat/high volume meal
    
  • •Rebound Tenderness
    
  • •Nausea and Vomiting
    
  • •Loss of Appetite— anorexia
    
  • •Gas— flatulence
    
  • •Heartburn— dyspepsia
    
  • •Fat in the stool–steatorrhea

• ---

  Labs:
  • -bilirubin
    
  • -CBC
    
  • -amylase and lipase

• ---

  Imaging:
  • -abd xray
    
  • -us of gallbladder
    
  • -oral cholecystogram
    
    • -patient takes iodine-containing tablets for 1-2 nights
      
    • -iodine absorbed, excreted into bile, outlines gallstones which are not dense to allow x-ray
  • -HIDA scan
    • radioactive imaging of the liver, gallbladder, and intestine

• ---

  Treatment:
  • Ursodeoxycholic acid
    
  • SURGERY
    
    • laparoscopic cholecystectomy (removal of GB)
      
    • Pre-op care:
      • •Standard preoperative care
        
      • •Operative procedure
        
    • •Postoperative care:
      
      • -Free air pain result of carbon dioxide retention in the abdomen
        
      • -Ambulation
        
      • -Return to activities in 1 to 3 weeks
    • T tube:
      • tube placed in the bile duct for drainage into a small pouch (bile bag) on the outside of the body
  • FOR PTS WHO CANT HAVE SURGERY
    
    • -extracorporeal shock wave lithotripsy
      
    • -drain placement
      
    • -stone dissolving drugs (expensive, takes up to 2 years, recurrence common)
      
    • -percutaneous transhepatic biliary catheter insertion
  • Nutrition Therapy:
    • low-fat diet, fat-soluble vitamins, bile salts
  • Drug therapy:
    • stone-dissolving drugs, bile salt reducing drugs (with severe obstructive jaundice), antibiotics, analgesics
  • Extracorporeal shock wave lithotripsy (ESWL):
    • breakdown of kidney stones using sound waves generated outside the body

Cholecystitis (acute)

• Path:
  • inflammation of the gallbladder

• ---

  Etiology:
  • -can happen with or without stones but most commonly with stones

• ---

  Presentation:
  • 1) Fever and ↑ WBCs
    
  • 2) Constant RUQ pain
    
  • 3) (+) murphy

• ---

  Type:
  • Acute cholecystitis:
    • -can happen with or without stones but most commonly with stones
  • Calculous cholecystitis:
    • Gallbladder inflammation associated with gallstones
  • Acalculous cholecystitis:
    • can occur in the absence of gallstones
  • Chronic cholecystitis:
    • repeated episodes of cystic duct obstruction in the result of chronic inflammation

• ---

  Diagnosis:
  • 1) US
    • – Pericholocystic fluid
    • – Gallbladder wall thickening
    • – Gallstones
  • 2) HIDA scan

• ---

  Treatment:
  • 1) NPO + IV fluids and abx
    
  • 2) Cholecystectomy (urgent)

Acalculous cholecystitis

• MC:
  • Critically ill pts (esp. hypotensive/those with long-term TPN)

• ---

  Cause:
  • Ischemia and cholestasis

• ---

  Treatment:
  • Emergent cholecystectomy or cholecystostomy (decompression)

Chronic cholecystitis

• Cause:
  • -pancreatitis, cholangitis
    
  • -jaundice
    
  • -icterus
    
  • -obstructive jaundice
    
  • -pruritis
    
  • -clay-colored stool and dark urine

Emphysematous cholecystitis

• Path:
  • Cholecystitis with air in the gallbladder wall

• ---

  Treatment:
  • Emergent cholecystectomy

Choledocholithiasis

• Path:
  • Stone lodged in biliary tree (common bile duct)

• ---

  Presentation:
  • Obstructive jaundice (jaundice w/RUQ pain)
  •  +/-hepatitis (↑ AST/ALT)
    
  •  +/- pancreatitis (↑ amylase/lipase)
    
  • can be asx
    
  • biliary colic
    
  • jaundice

• ---

  Lab:
  • Ball-valve effect
    
  • – transaminases rise and fall due to stone causing intermittent obstruction

• ---

  Imaging:
  • start with US; if inconclusive, MRCP or ERCP
  • US –> dilated ducts (obstruction)

• ---

  Treatment:
  • NPO + IV fluids 
    
  • stone extraction w ERCP
  • Cholecystectomy
    
  • abx if signs of infection

Ascending Cholangitis

• Path:
  • inflammation of the bile ducts
  • Biliary obstruction –> stasis –> infection

• ---

  Cause:
  • Gram (-) and anaerobes

• ---

  Other Types:
  • Suppurative cholangitis
    • Cholangitis complicated by shock
  • Primary sclerosing cholangitis
    • Cholangitis + sx of IBD (e.g. bloody diarrhea)

• ---

  Presentation:
  • Charcot’s triad:
    
    • RUQ pain,
      
    • jaundice,
      
    • fever
      
  • Reynold’s Pentad:
    
    • AMS
      
    • hypoTN
  • Elderly/immunosuppressed pts:
    • Altered mental status, ↓ WBCs, and hypothermia

• ---

  Physical Exam:
  • Reynold’s pentad: Charcot’s triad + hypotension + AMS

• ---

  Labs:
  • CBC: leukocytosis, left shift
    
  • CMP: elevated LFTs (ALT/ALP), hyperbilirubinemia
  • Raised CRP/WBC

• ---

  Diagnosis: 
  • US –> dilated ducts (obstruction)
  • ERCP (gold standard), CT, MRCP

• ---

  Treatment:
  • NPO, IVF
  • IV abx:
    
    • -community: cipro + metronidazole or Amp/Gent + MTZ
      
    • -hospital: zosyn or meropenem
      
  • ERCP extraction before surgery

Gallstone ileus

• Path:
  • gallstones in the terminal ileum

• ---

  Treatment:
  • Remove stone (leave gallbladder alone)

Cholecystectomy

• Post-op complications:
  • 1) Bleed
    
  • 2) Bile leak
    
    • – e.g. from cystic duct stump leak or CBD injury
      
  • 3) Post-cholecystectomy syndrome

PERC

• Percutaneous transhepatic cholangiography (PTC)
  • Alternative to ERCP for biliary decompression if it fails

• ---

  Surgery:
  • Alternative to PTC for biliary decompression if it fails

Bile duct injury

• Presentation:
  • Post-op ABD pain, bloating, and anorexia

• ---

  Work-up:
  • 1) Ultrasound/CT (look for fluid)
    
    • – Yes –> 2
      
  • 2) Sepsis?
    
    • – Yes –> fluid resuscitation, blood culture, abx, drainage –> 3
      
    • – No –> 3
      
  • 3) HIDA scan
    
    • – bile leak or no flow into duodenum –> 4
      
  • 4) ERCP

Choledochal cysts

• Path:
  • Congenital dilations of biliary tree

• ---

  Complications:
  • Cholangitis and malignancy

• ---

  Treatment:
  • Excision