Biliary Disorders (PEARLS + ReelDx)
The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint covers three topics associated with the gallbladder
| Acute and chronic cholecystitis |
Inflammation of the gallbladder; usually associated with gallstones
Presentation:
- 5 Fs: Female, Fat, Forty, Fertile, Fair
- (+) Murphy's sign (RUQ pain with GB palpation on inspiration)
- RUQ pain after a high-fat meal
- Low-grade fever, leukocytosis, jaundice
Diagnosis:
- Ultrasound is the preferred initial imaging - gallbladder wall >3 mm, pericholecystic fluid, gallstones
- HIDA is the best test (Gold Standard) - when ultrasound is inconclusive
- CT scan - alternative, more sensitive for perforation, abscess, pancreatitis
- Labs: ↑ Alk-P and ↑ GGT, ↑ conjugated bilirubin
- Porcelain gallbladder = chronic cholecystitis
- Choledocholithiasis = stones in common bile duct - diagnosed with ERCP (gold standard)
Treatment: Cholecystectomy (first 24-48 hours) |
| Cholangitis |
Infection of biliary tract secondary to obstruction, which leads to biliary stasis and bacterial overgrowth
- Characterized by pain in the upper-right quadrant of the abdomen, fever, and jaundice
- Choledocholithiasis accounts for 60% of cases
- Other causes include pancreatic and biliary neoplasm, postoperative strictures, invasive procedures such as ERCP or PTC, and choledochal cysts
- Organisms: E. coli, Enterococcus, Klebsiella, Enterobacter
Presentation:
- Charcot’s triad: RUQ tenderness, jaundice, fever
- Reynold’s pentad: Charcot’s triad + altered mental status and hypotension
Diagnostic studies:
- Initial imaging: Ultrasound
- Best: ERCP
Treatment: Cholangitis is potentially life-threatening and requires emergency treatment
- Aggressive care and emergent removal of stones, Cipro + metronidazole
- Antibiotics, fluids, and analgesia.
- ERCP to remove stones, insert a stent, repair the sphincter
- Cholecystectomy (performed post-acute)
Primary sclerosing cholangitis
- Jaundice and pruritus
- Associated with IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer
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| Cholelithiasis |
41 y/p female with severe right upper quadrant pain
A precursor to cholecystitis, cholesterol stones account for > 85% of gallstones in the Western world
- Stones in the gallbladder, pain secondary to contraction of gall against the obstructed cystic duct
- Asymptomatic (most), symptoms only last few hours
- Biliary colic—RUQ pain or epigastric
- Pain after eating and at night
- Boas sign—referred right subscapular pain
- RUQ ultrasound - high sensitivity and specificity if >2 mm. CT scan and MRI
TX: Asymptomatic—No treatment necessary
- Elective cholecystectomy for recurrent bouts
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