Gallbladder

Gallbladder-

-Acute/Chronic Cholecystitis-

-usually occurs as a complication of gallstone disease
-cholecystitis means inflammation of the gall bladder

-Acute cholecystitis is a syndrome of RUQ pain, fever, and leukocytosis associated with gallbladder inflammation that is mostly related to gallstone disease

-Acalculous Cholecystitis is identical to acute cholecystitis but does not involve gallstones

-Chronic cholecystitis describes chronic inflammatory cell infiltration of the gallbladder seen on pathology
-mostly seen in the presence of gallstones thought to be seen as a result of mechanical irritation of chronic attacks

-Acute cholecystitis occurs in the setting of cystic duct obstruction.  An additional irritant is needed to cause gallbladder inflammation.

-Clinical symptoms of acute cholecystitis include prolonged (over 4-6 hrs) of severe RUQ  or epigastric pain, fever, abdominal guarding, leukocytosis and a positive Murphy's sign
-Pain may radiate to the patients back or right shoulder
-may have associated nausea, vomiting, and anorexia
-patients are usually ill appearing, febrile, and tachycardic

-Patients typically have leukocytosis with increased number of bands, elevated total bilirubin and alkaline phosphatase

-Mirizzi Syndrome (a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct)

-Emphysematous Cholecystitis has a mild to moderate unconjugated hyperbilrubinemia that may be present because of hemolysis induced by a clostridial infection

-Confirmation of the diagnosis of cholecystitis requires demonstration of the gallbladder wall thickening or edema on an imaging study (usually ultrasound)

-Complications of cholecystitis include gangrene, perforation, cholecystoenteric fistula, gallstone ileus, or emphysematous cholecystitis

-Patients with acute cholecystitis should be admitted to the hospital and receive IV hydration, opioid analgesics and have electrolyte imbalances corrected
-Acute cholecystitis is an inflammatory process, secondary infection of the gallbladder can occur as a result of the cystic duct obstruction and bile stasis.
-It is not clear that antibiotics are required for the treatment of acute cholecystitis that is uncomplicated.  It doses not lower the risk of abscess or empyema but does lower the rate of bacteria and wound infection

-Patients definitively need their gallbladder removed at some point.


-Cholangitis-

-acute cholangitis is characterized by fever, jaundice, and abdominal pain
-acute cholangitis develops as a result of stasis and infection of the biliary tract
-acute cholangitis is referred to as ascending cholangitis

-acute cholangitis is caused by bacterial infection in a patient with biliary obstruction or stasis
-the organisms ascend through the duodenum via hematogenous spread from the portal vein
-causes of biliary obstruction include benign stenosis, malignancy, stent placement, and biliary stones
-E.Coli is the most common bacteria involved.  Enterbacter, Klebsiella,  Bacteroides, Clostridia and Enterococcus are other organisms involved

-Clinical presentation can involve Charcot's Triad:  fever, abdominal pain, and jaundice
-Reynold's Pentad includes Charcot Triad plus hypotension and confusion that can see with supprative cholangitis

-Labs reveal elevated WBC, elevated alkaline phosphatase, GGT, and bilirubin

-Tokyo Guidelines for diagnosis of acute cholangitis include (two or more of the following):  history of biliary disease, fever or chills, jaundice, and abdominal pain

-Diagnosis is considered definite if the patient has Charcot's Triad or if the patient has all of the following: evidence of inflammatory response (elevated WBC's or CRP), abnormal LFT's, or biliary dilatation

-Management includes monitoring and treating for sepsis, empiric antibiotic coverage (Unasyn or Zosyn), and establishing biliary drainage with ERCP

-Primary sclerosing cholangitis (PSC)is a chronic progressive disorder that has fibrosis, strictures of the medium an large ducts in the intrahepatic or extrahepatic biliary tree
-PSC eventually leads to complications of cholestasis and hepatic failure
-Needs a liver transplant eventually
-Most patients with PSC have ulcerative colitis
-Patients with PSC  may be asymptomatic until diagnosed on abnormal lab results or may be symptomatic
-PSC symptoms include jaundice, hepatomegaly, splenomegaly, pruritus, fatigue and excoriations
-Labs may reveal an elevated alkaline phosphatase, elevated bilirubin,  mildly elevated aminotransferases
-some patients with have high gamma globulin levels, increased IgM levels, atypical perinuclear antineutrophil cytoplasmic antibodies (P-ANCA), and Human Leukocyte Antigen DRw52a
-Ultrasound may have evidence of abnormal ducts but is usually not diagnostic
-Diagnosis is usually supported by characteristic appearance on cholangiography (MRCP, ERCP)
-Liver biopsy may support PSC


-Cholelithiasis-

 -the majority of patients with gallstones are asymptomatic
-about 20 percent of patients will develop symptomatic gallstones over 15 years

-major sequelae of gallstones include cholecystitis, choledocholithiasis, acute cholangitis, and gallstone pancreatitis
-acute cholecystitis is the most common complication
-choledocholithiasis is a stone in the common bile duct
-Sphincter of Oddi Dysfunction is a clinical syndrome of biliary or pancreatic obstruction related to mechanical or functional abnormalities of the sphincter or Oddi

-the four F's of gallbladder disease female (estrogen), fat (obesity), fertile (pregnancy), forty are conditions that cause biliary stasis

-patients with uncomplicated cholelithiasis present with RUQ or epigastric abdominal pain after eating.  The pain may radiate to the back.  There may be accompanied nausea and vomiting
-atypical symptoms may include chest pain or non specific abdominal pain
-if there is fever, jaundice, abnormal LFT's or abnormal pancreatic enzymes suggest a complication of gallstones
-Biliary colic is an intense, dull discomfort in the RUQ or epigastrium that radiates to the back or right shoulder.  The pain typically lasts for 30 minutes and plateaus after about an hour.  The pain usually resolves after 6 hours
-eating a fatty meal is a common trigger for gallbladder contraction

-physical exam reveals mild RUQ or epigastric tenderness.  These patients are usually not ill or febrile

-the study of choice for diagnosis is ultrasound.  CT scan of the abdomen is less sensitive
-HIDA scan is a test of biliary function or problem with cystic duct.  If reduced ejection fraction=biliary dyskinesia

-pain control can be achieved with NSAIDS or opioids
-cholecystectomy is eventually needed