PANCE Blueprint GI and Nutrition (9%)

Biliary Disorders (PEARLS + ReelDx)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint covers three topics associated with the gallbladder

Cholelithiasis vs. Cholecystitis vs. Choledocholithiasis vs. Cholangitis

Cholelithiasis Acute Cholecystitis Choledocholithiasis Cholangitis
The presence of gallstones in the gallbladder

A precursor to cholecystitis

Inflammation of the gallbladder usually due to gallstones Presence of gallstones in the common bile duct Infection/inflammation of the bile ducts
Formation of gallstones due to cholesterol or bilirubin Blockage of cystic duct by gallstones Migration of gallstones from the gallbladder to the common bile duct Blockage of bile ducts, often due to gallstones, leading to bacterial infection
Often asymptomatic; biliary colic Severe RUQ pain, low-grade fever, nausea, vomiting, positive Murphy’s sign RUQ pain, jaundice, dark urine, pale stools Charcot's triad: RUQ pain, fever, jaundice

Reynold's pentad: add hypotension and altered mental status

Ultrasound Ultrasound, HIDA scan (gold standard) ERCP, MRCP, ultrasound ERCP, MRCP, blood cultures
Asymptomatic: observation; symptomatic: cholecystectomy Antibiotics, cholecystectomy ERCP to remove stones, followed by cholecystectomy Antibiotics, ERCP to drain the bile duct
Biliary colic, acute cholecystitis Gallbladder gangrene, perforation Pancreatitis, cholangitis Sepsis, liver abscess, recurrent cholangitis
Acute and chronic cholecystitis
Patient will present as → a 40-year-old female presents with a 24-hour history of constant, severe right upper quadrant abdominal pain. She describes the pain as sharp and radiating to her back, worsening after meals. She also reports a low-grade fever and nausea. Her past medical history includes multiple episodes of similar but less severe pain. On examination, she has a fever of 38.2°C (100.8°F), and her right upper quadrant is notably tender with a positive Murphy’s sign. Laboratory tests show elevated white blood cell count and mild elevation in liver enzymes. An abdominal ultrasound reveals a thickened gallbladder wall and gallstones, consistent with acute cholecystitis. She is admitted for intravenous antibiotics and surgical consultation for cholecystectomy.

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
Patient will present as → a 58-year-old male with acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2 ° F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric, and the skin is jaundiced

Infection of the 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
Cholelithiasis
ReelDx Virtual Rounds (acute cholelithiasis)
Patient will present as → a 43-year-old woman who comes to the emergency department with a 12-hour history of right upper quadrant (RUQ) abdominal pain. The pain is severe now but waxes and wanes and is associated with nausea and some episodes of vomiting. The pain sometimes radiates through to the back. She feels warm but has not checked her temperature. There is no diarrhea. Her last bowel movement was 1 day ago and was normal. The patient has no similar history in the past. On examination, the patient is an obese young woman in some discomfort. Her vital signs reveal a temperature of 100 ° F and pulse of 102 beats/ minute. Her blood pressure is 130/70 mmHg, and her respirations are 18 breaths/minute. There is no scleral icterus. The chest is clear, and the cardiovascular examination is normal. Abdominal examination reveals marked upper abdominal tenderness with guarding, especially in the RUQ. On palpation of the RUQ of the abdomen when the patient is asked to take a deep breath, there is a marked increase in pain. The bowel sounds are present but seem slightly sluggish. The patient has no drug allergies and is not taking any medications at present.

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 a few hours
  • Biliary colic—RUQ pain or epigastric
  • Pain after eating and at night
  • Boas sign—referred right subscapular pain

DX: 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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