This is based on approach to a patient presenting to emergency department complaining of right hypochondriac pain. It includes anatomy, pathophysiology, epidemiology, clinical assessment, investigation, management, complication and disposition of a biliary infection.

1. BILIARY EMERGENCIES
DR KTD PRIYADARSHANI
REGISTRAR EMERGENCY MEDICINE

2. Scope
 Anatomy
 Pathophysiology
 Epidemiology
 Clinical assessment
 Investigation
 Management
 Complications
 Disposition

3. Anatomy

4. Pathophysiology

5. Epidemiology
 Gallstones >95% of biliary tract diseases
 Prevalence of gallstones in adults in developed countries is -20% and rising.
 Twice often in women as men, 1/5 women affected by gallstones by age of 60 (oxford-2016)
 Risk factors
 Physical inactivity
 Obesity
 Insulin resistance & DM
 NAFLD
 Drugs- HRT
 Gall bladder hypomobility( rapid weight loss, prolonged fasting)

6. Epidemiology
 Gallstones*
 80%- remain asymptomatic throughout life time
 10% become symptomatic with in 5 yrs
 20% become symptomatic with in 20 yrs
 Clinical presentation of gall stone pathologies
 Asymptomatic cholelithiasis & choledocholithiasis (80%) to acute cholecystitis
& acute cholangitis
 Pitfalls
 Symptoms attribute to incidental gallstones
 Biliary colic is a misnomer. Pain lasting >6hr is a red flag!
* Van Dijk AH, de Reuver PR, Besselink MG etal. Assessment of available evidence in the management of gallbladder and bile duct stones:
a systematic review of international guidelines 2016

7. Clinical Assessment
 Biliary colic/ cholelithiasis
 Usually resolves within 6 h
 Associated with radiation to the right shoulder (60%)
 Recurrent attacks
 Associated with an urgency to walk (66%)
 No systemic inflammatory signs
 Murphy’s sign positive (sensitivity 65%, specificity 87%)
 Afebrile

8. Clinical Assessment
 Acute cholecystitis
 Unremitting RUQ pain & fever
 The absence of RUQ tenderness has a negative likelihood ratio of 0.4
 Murphy’s sign has low sensitivity and a high specificity, with a positive likelihood
ration of 14
 Murphy’s sign is less reliable in the elderly
 Elevated inflammatory markers
 Normal LFT
 No single clinical or laboratory findings with sufficient diagnostic accuracy to
confirm or exclude

9. Clinical Assessment
 Choledocholithiasis
 Biliary colic and jaundice with an elevated bilirubin (>2 mg/dL)
 Concomitant elevation of GGT and ALP (90% Sensitive)
 Elevated LFTs >1.5 ULN (94% sensitive)
 Elevated lipase levels suggests the presence of an obstructing common bile
duct stone

10. Clinical Assessment
 Acute cholangitis
 Average age 50-60 yrs
 Abdominal pain (60-70%) + signs of cholestasis + fever (>90%)
 Charcot’s triad ( abdominal pain, fever, jaundice) has a low sensitivity (26.4%) but high
specificity (95.9%)
 Reynolds’ pentad ( charcot’s triad + altered mental status + shock) is observed in fewer than
10% of patients
 Elevated inflammatory markers and leukocytosis (>80%)
 Positive blood culture (70%)
 Biliary stenting and instrumentation of the biliary tree are common predisposing factors (post
ERCP 0.5-5%)

11. Tokyo 2018 diagnostic criteria acute cholecystitis
A Local signs of inflammation • Murphy’s sign
• RUQ mass, pain and/or tenderness
B Systemic signs of
inflammation
• Fever >38’C
• CRP >3mg/L (28.5 nmol/L)
• WBC count >10,000
C Imaging findings • USS with gallbladder wall thickening,
pericholecystic fluid or a sonographic
Murphy’s sign
• Other imaging modalities are acceptable
A+ one item in B without imaging findings= suspected diagnosis
A+ one item in B+C (suspected+ imaging findings)= definite diagnosis
Sensitivity 91.8% & specificity 77.7%
Limitation – mild disease, without systemic inflammatory response & imaging is difficult to perform

12. Tokyo 2018 diagnostic criteria acute cholangitis
A Evidence of
systemic
inflammation
• Fever >38’C or rigors
• Lab abnormalities
• WBC <4 or >10
• CRP >1 mg/L
B Evidence of
cholestasis
• Jaundice
• T Bil >2 mg/dL
• Abnormal LFTs
• ALP >1.5 ULN
• GGT >1.5 ULN
• AST >1.5 ULN
• ALT >1.5 ULN
C Imaging findings • Biliary dilatation
• Evidence of stricture, stone or stent
A+ one item in either B or C= suspected diagnosis
One item in A,B & C= definitive diagnosis
Sensitivity 91.8% specificity 77.7%

13. Severity assessment
Grade I (mild)
Cholecystitis &
cholangitis
Grade II (moderate)
cholecystitis
Grade III (severe)
Cholecystitis & cholangitis
Diagnosis of cholecystitis
or cholangitis with NO
criteria of Grade II
(Moderate) or Grade III
(severe) disease
Cholecystitis + any ONE of the following
• WBC >18,000
• Palpable tender RUQ mass
• Length of illness >72 hrs
• Severe local inflammation
• Gangrenous cholecystitis
• Pericholecystic abscess
• Hepatic abscess
• Biliary peritonitis
• Emphysematous cholecystitis
Diagnosis of cholecystitis or cholangitis+ any one of
the following findings of associated organ dysfunction
• Hypotension requiring any dose of norephinephrine
or >5 microg/kg/min dopamine
• Altered mental status
• PaO2/FiO2 <300
• Oliguria or serum creatinine >2 mg/dL
• INR >1.5
• Thrombocytopenia <100,000
Cholangitis + any 2 of following
• WBC >12 or <4
• Fever >39’C
• Age >75
• T Bil>5 mg/dL
• Hypoalbuminemia (<0.7 LLN)

14. Investigations
 USS
 Good sensitivity and specificity for cholelithiasis and cholecystitis, but lacks
adequate sensitivity for choledocholithiasis
 Cholelithiasis >95% sensitivity and specificity
 Acute cholecystitis 81% sensitivity & 83% specificity
 Sonographic Murphy’s sign 85-98% sensitivity & 82-95% negative predictive value
 Choledocholithiasis
 Common bile duct stones- 27% - 49% sensitive & 99-100% specific
 Common bile duct dilatation- 28%-56% sensitive & 94-98% specific

16.  CT Abdomen/pelvis
 with IV contrast- more effective at diagnosis choledocholithiasis
 Sensitivity 85-97% specificity 88-96%
 Test of choice for evaluating patients with suspected acute cholangitis
 Complications- gangrenous cholecystitis, gallstone ileus & GB perforation
 MR Cholangiopancreatography
 To confirm choledocholithiasis in patients at intermediate risk
 Sensitivity & specificity are similar to USS
 Less interpreter variability, alternative for difficult us candidates

18.  Technicium 99m hepatobiliary iminodiacetic acid cholescintigraphy (HIDA)
 96% sensitive & 90% specific
 Recommended when the initial ultrasound is equivocal or inconstant with the
patient's clinical presentation
 Reveal delayed GB emptying ( Biliary dyskinesia)
 Require hours to perform

20.  Systemic inflammation
 FBC
 CRP
 Liver function tests
 Bilirubin, ALT, AST, ALP, Gamma GT- Often normal
 Gamma GT- Most sensitive and specific serum marker of
choledocholithiasis
 Procalcitonin level– at admission shown to predict severity of
acute cholangitis
 To identify severe disease who may benefit from urgent
decompression from moderate disease who may tolerate a delayed
definitive RX

21. Management
 NBM
 Volume & electrolyte replacement
 Antiemetics
 Anticholinergic atropine or glycopyrrolate- no evidence to improve biliary colic
 Analgesics
 NSAIDs- 1st line therapy
 Opioids – sphincter of oddi spasm
 Empiric IV antibiotics
 Based on local ST & disease severity

22. Community acquired biliary infection
Grade I (mild) Grade II (moderate) Grade III (Severe)
1st to 3rd generation
cephalosporins
Or ertapenem 1g IV once
daily
Or fluoroquinolone
(if biliary enteric
anastomosis, consider
additional anerobic
coverage with
metronidazole)
Piperacillin- tazobactam
or 3rd or 4th generation
cephalosporin
Or ertapenem 1g IV once
daily
Or fluoroquinolone
Treat as health care
associated
vancomycin or
alternative
+ piperacillin tazobactam
Or carbapenem alone

23. Health care associated biliary infection (any severity) A+B+/-C
A B C
Vancomycin 15-20
mg/kg IV 8-12 h
or Linezolid 600mg IV 12
hr
Or daptomycin 6mg/kg
24h
Piperacillin-tazebactam
3.375 g Iv 6H
Or antipseudomonal
cephalosporin
Or carbapenem
Or aztreonam 2g IV
In the presence of a
biliary enteric
anastomosis add
Metronidazole loading
dose, 15mg/kg IV over
1h, maintenance dose
7.5mg/kg IV 6H

24.  Surgical options
 Acute cholecystitis- early laparoscopic cholecystectomy (with in 72 hrs)
 High operative risk or acalculous cholecystitis- percutaneous cholecystostomy
 Choledocholithiasis – ERCP / stone extraction & sphincterotomy
 Same admission cholecystectomy* (strongly recommended) or interval
cholecystectomy
 Acute cholangitis- ERCP
 near 100% mortality if treatment is delayed.
 Overall mortality <10% after biliary drainage
 Interval cholecystectomy once infection resolves
 Biliary stenting
 Limited life expectancy & high surgical risk
*ASGE standards of practical committee, Buxbaum JL, abbas Fehmi SM et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis 2019

25. Complications
 Gall bladder empyema
 Same presentation as acute cholecystitis
 Associated with a palpable distended gallbladder that is markedly tender on
even superficial palpation
 Risk of perforation / generalized sepsis
 Pip taz as 1st line
 Urgent decompression is the goal of therapy
 Initial laproscopic cholecystectomy ( higher incidence of conversion to open 40-80%)
 Maitain IV ab until fever resolves & WBC return to normal

26. Complications
 Gangrenous cholecystitis
 Necrosis and gangrene of gallbladder
 Following progressive vascular insufficiency
 Significant high mortality

27. Complications
 Emphysematous cholecystitis
 when inflamed gall ladder become infected with gas producing organisms
 Clostridium species, E.Coli & Klebsiella species
 Gas in GB wall or lumen
 Associated with DM, older patients
 Plain radiographs, US, IV contrast enhanced CT
 High mortality
 Need urgent cholecystectomy / percutaneous cholecystoatomy

28. Complications
 Gall bladder perforations
 Uncommon but life threatening
 Neimeier (1934) classification
 Acute/type I- free GB perforation & generalized biliary peritonitis
 Subacute/Type II- pericholecystic abscess & localized peritonitis
 Chronic/ type III- cholecystoenteric fistula
 CT shows more accurate signs of free fluid, pericholecystic fluid & abscess than
USS
 Cholecystectomy+ drainage of abscess + abdominal lavage +/- repair of fistula

29. Complications
 Gallstone ileus
 Mechanical small bowel obstruction by ectopic
gall stone reached the intestinal lumen via a
biliary enteric fistula
 Plain xray, CT
 Rigler’s triad
 Small bowel obstruction
 Pneumobilia
 Ectopic gallstone
 Operative therapy

30. Complications
 Post cholecystectomy syndrome
 Persistent abdominal symptoms after removal of the GB
 Early period- Bile leak is the principal concern
 Leucocytosis & abnormal LFTs
 Abdominal USS or CECT can detect pathologic bile collections

31. Complications
 Chronic cholecystitis
 GB inflammation & scarring
 Thickened GB wall, mucosal atrophy & fibrosis
 Symptoms & examination findings are more subtle

32. Complications
 Acalculous cholecystitis is rare (5-10% of cases). However it carries a
mortality of 30-90% in critically ill patients.
 Risk factors for acalculous cholecystitis
 Critical illness
 Major trauma
 Postoperative status
 Multi organ failure
 Diabetes
 Immunosuppression
 Severe burns

33.  Hypoperfusion of GB & subsequent wall ischemia & inflammation
 Definitive treatment- gallbladder drainage- commonly with a
percutaneous cholecystostomy

34. Disposition
 Discharge home
 Uncomplicated biliary colic that resolves- strict return precautions for
worsening symptoms or the development of fever or jaundice
 1-2 wk follow up for an elective cholecystectomy
 Admission
 Acute cholangitis- for IV ab and evaluation for biliary drainage
 Sepsis/shock and organ dysfunction- require ICU admission
 Acute cholecystitis- for IV ab & surgery or bilary drainage

35. Prevention
 Lifestyle changes
 Maintain ideal BW
 Strict glycemic control
 Regular, moderate physical activity
 Pharmacological prevention is not recommended
 Promote regular GB emptying
 Diet rich in fiber & Ca
 Regular pattern of eating

36. References
 2018 Tokyo guideline
 Tintinali’s emergency medicine -9 th edition
 ASGE standards of practical committee, Buxbaum JL, abbas Fehmi SM et al.
ASGE guideline on the role of endoscopy in the evaluation and
management of choledocholithiasis
 Van Dijk AH, de Reuver PR, Besselink MG etal. Assessment of available
evidence in the management of gallbladder and bile duct stones: a
systematic review of international guidelines 2016
 Choi, H.J., Cho, S.J., Kim, OH. et al. Efficacy and safety of a novel topical
agent for gallstone dissolution: 2-methoxy-6-methylpyridine. J Transl
Med 17, 195 (2019). https://doi.org/10.1186/s12967-019-1943-y