When to take out a gallbladder in an asymptomatic patient
Porcelain gallbladder (50% risk of adenocarcinoma) and stones > 3cm. Otherwise less than 10% of patients with asymptomatic gallstones develop symptoms requiring surgery over 5 years.
In a patient presenting with RUQ pain, what biliary dx is less likely if the patient does NOT have a fever?
Differential of RUQ pain in a young female?
Gastroenteritis, PUD, acute hepatitis, renal colic, pleural-based pneumonia, gallstone disease and pyelonephritis.
Boaz sign and Murphey sign
Boaz = pain radiates to right scapula. Murphey: inspiratory arrest during deep RUQ palpation. Both indicate gallstone disease.
Labs to order in patients with suspect gallstone disease?
CBC (mild leukocytosis is prevalent in uncomplicated cholelithiasis), LFTs (20% may have bili of 2-3, alk phos may also be elevated), amylase and lipase (check for pancreatic occlusion).
What classification does a cholecystectomy fall under as far as sterility goes?
Clean-contaminated, patients get a single preop dose of 1st generation cephalosporin.
Who receives more than the single pre-op dose of 1st generation cephalosporin for a lap chole?
Age > 70, acute cholecystitis, hx of obstructive jaundice, choledocolithiasis or jaundice. These patients all have a higher risk of developing septic complications.
2 major complications of lap chole
CBD injury (may result in chronic strictures, infection, cirrhosis) and proper hepatic artery ligation (may result in hepatic ischemic injury, bile duct ischemia, stricture)
A patient presents with RUQ pain, fever, elevated WBC, elevated alk phos and gallstones on RUQ u/s w/inflamed GB wall and pericholecystic fluid. How do you manage her?
IVF resuscitation, NPO, +/- NG if nausea/vomiting, preop abx, lab chole within 48-72 hours and post op abx for 24 hours.
Bugs and drugs for acute cholecystitis with cholelithiasis
Bugs: E. coli, Enterobacter, Klebsiella, Enterococcus. Drug: 2nd generation cephalosporin pre-op and for 24 hours post-op
How do you manage a patient presenting with symptomatic cholelithiasis, elevated AST/ALT, gallstones on RUQ u/s and a bilirubin of 4 mg/dL?
The presence of jaundice and elevated liver enzymes with gallstones likely indicates choledocolithiasis. In this patient it is essential to clear the CBD of stones w/ERCP followed by lap chole OR lap chole + intraop cholangiogram + CBD exploration OR lap chole + postop ERCP. Note that some surgeons are okay with observation for stones < 3mm.
How many pregnant women typically have gallstones?
3-11%, asymptomatic in most cases, this is due to increased estrogen causing cholestasis.
When to operate on a pregnant woman with symptomatic cholelithiasis or gallstone pancreatitis.
Recurrent episodes, acute cholecystitis, obstructive jaundice or peritonitis -> surgery or ERCP w/sphincterotomy, most preferably in 2nd trimester. Otherwise, hydration and pain management is appropriate with lap chole after delivery.
A patient presents with symptomatic cholelithiasis, gallstones on RUQ u/s and a mildly elevated serum amylase. How do you manage this patient?
Cholecystectomy + operative cholangiogram (mandatory w/biliary pancreatitis) if the patient has mild pancreatitis. If the patient has fluid sequestration, hypocalcemia, oliguria, hypotension or pulmonary complications secondary to pancreatitis, the cholecystectomy should be delayed, the patient should be resuscitated and ERCP is warranted if CBD is dilated or there are stones in the distal CBD.
What is the mechanism for the complications associated with pancreatitis?
Release of zymogens results in inflammation, PMN recruitment and release of cytokines (TNF-alpha and IL-1). This results in increased capillary permeability, hypovolemia, DIC, ARDS and eventually end-organ failure (esp. renal failure).
Complications of gallstone disease that presents with fevers.
Acute cholecystitis, cholangitis, empyema or the gallbladder or pericholecystic abscesses.
Fever and RUQ pain, RUQ u/s shows fluid with internal echoes and stones. What is your dx and how do you tx?
Empyema. Pt needs IV abx and emergent exploration with cholecystectomy. PTC to drain the gallbladder can be done if pt health is poor and cannot tolerate an operation.
Fever, jaundice and RUQ pain, RUQ u/s shows prior cholecystectomy and dilation of CBD and air in the biliary system. What is your dx and how do you tx?
Suppurative cholangitis due to bacterial infection of gas-forming organisms proximal to biliary obstruction. Tx with rapid stabilization with IVFs/abx and emergent ERCP w/sphincterotomy to decompress biliary tree and remove stones. If ERCP is unsuccessful, you can call IR to do transhepatic cholangiogram w/stone extraction or go to the OR for cholecystectomy w/CBD drainage.
Tx for acute biliary sepsis
IVF resuscitation/abx and urgent surgery.
An elderly patient presents with a tender 3cm palapable mass in the RUQ, a temp of 103 and obtundation. How do you manage this patient? What if there was air seen in the gallbladder wall on RUQ u/s?
This patient has an inflamed gallbladder that is palpable because of omentum adhearing to it due to inflammation. As soon as this patient is resuscitated he needs emergent cholecystectomy due to high risk of GB rupture. Air in the GB wall indicates emphysematous GB and merits similar tx.
A patient presents with recent onset of jaundice, fever and RUQ pain. RUQ u/s shows no gallstones, but dilation of the CBD is noted. How do you tx this patient?
IVFs/abx and ERCP for biliary decompression. This patient most likely has acute cholangitis.
What differentiates a retained gallstone from a primary CBD stone?
Retained stones occur within 2 years of cholecystectomy. After 2 years = CBD stone.
How do we get gallstones out of the CBD?
ERCP +/- sphincterotomy, PTC or operative duct exploration if the 1st 2 measures fail.
How do you tx a patient with jaundice and RUQ pain secondary to biliary stricture after he had cholecystectomy?
Surgical bypass of the stricture with choledochojejunostomy. Endoscopic dilation can be considered but is less beneficial.
Gallstones not well visualized by u/s
Distal CBD stones because intestinal gas gets in the way, use CT or ERCP. u/s is good for cystic duct and proximal CBD visualization.
Your patient is POD 1 from lab chole and presents with fever and abdominal pain. What 2 things are you worried about and how do you rule them out at this point?
1) Biliary leak 2) Infection. 1) HIDA scan: patient must have bili < 8-10 for it to work, hepatoiminodiacetic acid is injected IV and is excreted along the biliary tract, it will show you leaks (and acute cholecystitis if the GB fails to visualize). RUQ u/s is also used to look for fluid collections. CT can be used to r/o hepatic abscesses proximal to old obstruction. 2) CBC should give you enough info to suspect infection.
What do you do if your postop patient has a leakage on HIDA scan that was confirmed to be at the cystic duct stump seen on ERCP?
Biliary drainage with temporary stent placement. Exploration if the patient does not improve rapidly.
What is your differential diagnosis in a 55 year old man with recent onset jaundice and pruritis w/labs: direct bili 6, AST 18, ALT 18 and alk phos 6x normal? ee
Obstructive jaundice: adenocarcinoma in pancreatic head (associated w/weight loss, vague back pain and tobacco), periampullary carcinoma, cholangiocarcinoma (associated w/weight loss, vague back pain and tobacco), CBD stricture (chronic alcoholism or prior biliary surgery) or CBD stone impacted in ampulla (sx are typically intermittent).
What is a Klatskin tumor? How do you work one up? How do you treat it?
Cholangiocarcinoma at the bifurcation of the hepatic bile ducts. Dx w/PTC or ERCP to demonstrate the level of obstruction and get biopsies. Tx exploration and resection of bile ducts and gallbladder if there is no evidence of metastasis or local spread +/- hepatic lobectomy if tumor extends into hepatic ducts. Note however, that most tumors are unresectable and have a poor prognosis (5-15%) due to high rates of vascular invasion and mets and can be treated with palliative stenting.
A 55 year old man presents with painless jaundice and vague back pain. CT of the abdomen reveals no masses in the head of the pancreas, no gallstones and dilation of the CBD. What is the next step?
CT can miss tumors in the head of the pancreas. Endoscopic u/s through the duodenum can visualize the head of the pancreas well and can be combined with ERCP for biopsy and further assessment.