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Gallbladder Disease
Gazi Rashid
Lindsey Urquia
5 Takeaways
1. Basic HPB layout and 2 important views during surgery
2. Different types of gallstones and their risk facto...
• Anatomy : Gazi - 5 min
• Minor: Symp Chole, Choledocho,
• Physiology/types of GS/risk factors: Lindsey - 5 min
• GB path...
Anatomy
Draw the hepatobiliary system - gallbladder, liver,
pancreas, duodenum, and what connect them
CDB
- Choledocholithiasis
- Ascending Cholangitis
- Cholangiocarcinoma
- Strictures from ERCP
Gallbladder
- Cholelithiasis...
Historical
Triangle
of Calot
Modern
Triangle
of Calot
Critical View
of Safety
Types of gallstones/risk factors
• Biliary sludge – cholesterol crystals, Ca bilirubinate granules & mucin
maxtrix
• Impai...
Cholelithasis
Acute cholecystitis
• Pain – unrelenting right upper quadrant, midepigastric pain
• Vs. Biliary colic
• Nausea & vomiting
...
Normal Gallbladder
imaging
Acute Cholecystitis
imaging
Acute Cholecystitis
imaging
HIDA Scan
(Hepatobiliary Iminodiacetic acid)
imaging
If there’s a question…get a HIDA
Highly sensitive & specific! (95%)
Positive HIDA scan =
Acute Cholecystitis
imaging
Acute Cholecystitis
imaging
Acute Cholecystitis medical mang
treatment
• NPO
• IV fluids
• IV antibiotics
• E. Coli, Klebsiella, Enterobacter, Bactero...
Cholecystectomy
treatment
• NPO, IVF, IV abx
• Classic: Surgery safe if within 72 hours
• Identify anatomical views & crit...
Cholecystectomy
treatment
Ascending cholangitis
- Terms: Choledocholithiasis vs. Ascending
Cholangitis
- Acute Presentation (Charcot’s Triad):
- Jau...
Workup
● Leukocytosis
● Cholestatic Pattern
of Liver Injury
○ ALP, GGT,
Bilirubin >>>
AST, ALT
○ All can be
elevated
● RUQ...
Management of Ascending Cholangitis
- Mild ←→ Emergency!
- Unstable patients: aggressive medical management, ICU
- BP cont...
Porcelain Gallbladder
imaging
Gallstone Ileus
• Misnomer!
• Mechanical obstruction
• Large impacted stone →
Ischemia & pressure necrosis →
Erosion into ...
Gallstone Ileus
Presentation
• Elderly women with hx of biliary disease
• Small bowel obstruction symptoms
• N/V, diffuse ...
Case 1
42 y/o woman presents to clinic with abdominal pain
1. History – LOCATES
2. Physical exam
3. DDx
4. Labs
5. Managem...
Case 1
pathology
• 42 y/o female with a 2 day history of RUQ &
right upper back pain, assoc nausea.
What’s your differenti...
Acute Cholecystitis
imaging
Diagnosis
diagnosis
• History & physical exam
• Ultrasound
• 95% sensitive
• Hyperechoic mobile densities within gallbladd...
Case 2
25 y/o female with a 2-day hx of fevers, chills, constant RUQ pain,
scleral icterus, nausea, vomiting, BP 90/54, HR...
Acute cholecystitis
RUQ pain, nausea/vomiting, fever, increased WBC
U/S (1st line): pericholecystic fluid, GB wall > 3mm t...
Symptomatic cholelithasis
Intermittent RUQ pain, nausea, fever unlikely
Diagnosis H&P, Ultrasound
Gallstone Ileus
1 liner:...
Appendix
Case 2
pathology
• 79 y/o female with a 5 day history of diffuse
abdominal pain, nausea, vomiting
What’s your differential...
Gallbladder Carcinoma
pathology
• 0.5-1% of pop with cholelithiasis
• Poor prognosis (unless T1a)
• Most adenocarcinoma
• ...
Gallbladder Carcinoma
treatment
• Localized (lamina propria)
• Cholecystectomy
• Advanced Stage
• radical cholecystectomy
...
Mirrizzi Syndrome
pathology
Common hepatic duct obstruction 2/2
impacted stone in cystic duct
Biliary Dyskinesia
pathology
• Impaired GB emptying or
sphincter of Oddi relaxation
• Biliary colic (post-prandial
sharp R...
Acalculous Cholecystitis
pathology
• Seen in critically ill pt
• Trauma
• Burn
• Prolonged TPN or NPO status (weeks)
• Car...
Imaging in Gallstone Ileus
Imaging
Gallbladder Disease
Gallbladder Disease
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Gallbladder Disease

Lecture given for surgery clerkship

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Gallbladder Disease

  1. 1. Gallbladder Disease Gazi Rashid Lindsey Urquia
  2. 2. 5 Takeaways 1. Basic HPB layout and 2 important views during surgery 2. Different types of gallstones and their risk factors 3. Walk through an H&P & workup for acute cholecystitis 4. Basics of Medical vs. Surgical mgmt for acute cholecystitis 5. Presentation and acute management of ascending cholangitis Extra: Recognize a. Basic presentation & pathophys of gallstone ileus b. Imaging & management of Porcelain GB c. Surgical indications for asymptomatic cholelithiasis
  3. 3. • Anatomy : Gazi - 5 min • Minor: Symp Chole, Choledocho, • Physiology/types of GS/risk factors: Lindsey - 5 min • GB pathology • Acute chole: Lindsey - 15 min • Patho → Pres • DDx • W/U – Labs, Imaging • Medical • Operative • Ascending chol : Gazi - 10 min • Patho → Pres (Triad, Pentad) • W/U → labs, imaging • Med/ICU mgmt • Operative/ERCP • Cases – core info (x3) - 10 min (6, 4) - I don’t know that we’ll have time to do 3 cases • Biliary colic-– Lindsey/Gazi + counseling • Acute Chole - 1 liner→ diagnosis: history/PE/labs/US/management - 5 Qs each - maybe include the “Pearls” here • Asc Chol - 5 review Qs, as this isn’t a typical H&P • Misc - Porcelain GB, Gallstone Ileus (5 min) • “pearls”– • Time for questions - 10-15 min (mention oral exams, resources to learn rest of biliary dz) • Appendix - at their own pleasure
  4. 4. Anatomy Draw the hepatobiliary system - gallbladder, liver, pancreas, duodenum, and what connect them
  5. 5. CDB - Choledocholithiasis - Ascending Cholangitis - Cholangiocarcinoma - Strictures from ERCP Gallbladder - Cholelithiasis - Asymp. Vs Symp - Calculous Cholecystitis - Porcelain GB - Gallstone Ileus - Acalculous Cholecystitis - Gangrenous Cholecystitis - GB Carcinoma Cystic Duct - Mirizzi Syndrome Cancer at the Head of the Pancreas Sphincter of Oddi Biliary Dyskinesia
  6. 6. Historical Triangle of Calot
  7. 7. Modern Triangle of Calot
  8. 8. Critical View of Safety
  9. 9. Types of gallstones/risk factors • Biliary sludge – cholesterol crystals, Ca bilirubinate granules & mucin maxtrix • Impaired/slow contractility or bile stasis • Cholesterol (70-80%) • Most common • Increased ratio of chol:salts • Hormone (preg, OCP) • Pigmented (20-30%) • Bilirubin & calcium salts (20% cholesterol) • Cirrhosis, hemolytic anemia, hereditary spherocytosis
  10. 10. Cholelithasis
  11. 11. Acute cholecystitis • Pain – unrelenting right upper quadrant, midepigastric pain • Vs. Biliary colic • Nausea & vomiting • Fever/chills • Labs * - elevated enzymes/Br but relatively low • Obstruction of cyst duct from gallstone • 95% - calculi • 5% - acalculous (sludge) • GB continues to produce mucous ➔ distension ➔ venous congestion inflamed, edematous wall ➔ arterial inflow impaired ➔ stone dislodges (ischemia 5-10%)
  12. 12. Normal Gallbladder imaging
  13. 13. Acute Cholecystitis imaging
  14. 14. Acute Cholecystitis imaging
  15. 15. HIDA Scan (Hepatobiliary Iminodiacetic acid) imaging If there’s a question…get a HIDA Highly sensitive & specific! (95%)
  16. 16. Positive HIDA scan = Acute Cholecystitis imaging
  17. 17. Acute Cholecystitis imaging
  18. 18. Acute Cholecystitis medical mang treatment • NPO • IV fluids • IV antibiotics • E. Coli, Klebsiella, Enterobacter, Bacteroides, Clostridium coverage • 2nd gen cephalosporin (cefoxitin) • Fluoroquinolones (Ciprofloxacin, Levofloxacin) • Ampicillin-sulbactam (Unasyn) • Surgery!
  19. 19. Cholecystectomy treatment • NPO, IVF, IV abx • Classic: Surgery safe if within 72 hours • Identify anatomical views & critical view • Intraoperative cholangiogram (IOC) – high suspicion for CBD stone • Lap > open conversion rate 0-20%
  20. 20. Cholecystectomy treatment
  21. 21. Ascending cholangitis - Terms: Choledocholithiasis vs. Ascending Cholangitis - Acute Presentation (Charcot’s Triad): - Jaundice, RUQ pain, Fever - Complicated by Reynold’s pentad: Triad + Hypotension + AMS (Septic shock) - Not always due to stones!
  22. 22. Workup ● Leukocytosis ● Cholestatic Pattern of Liver Injury ○ ALP, GGT, Bilirubin >>> AST, ALT ○ All can be elevated ● RUQ U/S: ○ Stone not always seen ○ Look for CBD dilatation
  23. 23. Management of Ascending Cholangitis - Mild ←→ Emergency! - Unstable patients: aggressive medical management, ICU - BP control:fluids, fluids, fluids - Monitoring - Blood cultures - Treatment: - IV broad spectrum antibiotics - Biliary decompression with ERCP (1st line) - Cholecystectomy when stable
  24. 24. Porcelain Gallbladder imaging
  25. 25. Gallstone Ileus • Misnomer! • Mechanical obstruction • Large impacted stone → Ischemia & pressure necrosis → Erosion into intestines → cholecystic-enteric fistula • Bowel obstruction when stone is stuck at ileo-cecal valve
  26. 26. Gallstone Ileus Presentation • Elderly women with hx of biliary disease • Small bowel obstruction symptoms • N/V, diffuse abd pain, obstipation Imaging (plain films, CT scan) • Bowel obstruction findings: Air-fluid levels • Pneumobilia (gas in biliary tree) • Ectopic large gallstone
  27. 27. Case 1 42 y/o woman presents to clinic with abdominal pain 1. History – LOCATES 2. Physical exam 3. DDx 4. Labs 5. Management Bonus: What if this patient was asymptomatic and found – when would you do a cholecystectomy?
  28. 28. Case 1 pathology • 42 y/o female with a 2 day history of RUQ & right upper back pain, assoc nausea. What’s your differential diagnosis? • Worse after meals. Similar episodes in the past. No f/c • Meds – OCP, MVI • PMH/PSH – HTN, hyperlipidemia, Lap gastric banding
  29. 29. Acute Cholecystitis imaging
  30. 30. Diagnosis diagnosis • History & physical exam • Ultrasound • 95% sensitive • Hyperechoic mobile densities within gallbladder with assoc hypoechoic shadowing
  31. 31. Case 2 25 y/o female with a 2-day hx of fevers, chills, constant RUQ pain, scleral icterus, nausea, vomiting, BP 90/54, HR 117, T 39.1: 1) Next steps of management? 2) Other DDx? 3) Workup (Labs, Imaging, etc)? 4) What will 1st line imaging show? 5) What is the 1st-line therapeutic intervention? Describe it. Bonus: The pt.tells you that she’s had mouth sores & bloody diarrhea for months - what is the underlying pathology in this presentation?
  32. 32. Acute cholecystitis RUQ pain, nausea/vomiting, fever, increased WBC U/S (1st line): pericholecystic fluid, GB wall > 3mm thick, stones, sonographic Murphy’s HIDA 95% accurate Anatomy Modern Triangle of Calot: Cystic Artery, Hepatic Duct, Inf Liver Edge CVS: See cystic artery and cystic duct entering GB Acute cholangitis Charcot triad: (1) fever/chills + RUQ pain + jaundice Reynold’s pentad: Charcot’s triad + altered mental status + shock Emergency! Need ERCP summary
  33. 33. Symptomatic cholelithasis Intermittent RUQ pain, nausea, fever unlikely Diagnosis H&P, Ultrasound Gallstone Ileus 1 liner: Elderly women w/ SBO & history of biliary disease Transition point at ileocecal valve (stuck) Porcelain gallbladder Asymptomatic 25-50% assoc with gallbladder cancer summary
  34. 34. Appendix
  35. 35. Case 2 pathology • 79 y/o female with a 5 day history of diffuse abdominal pain, nausea, vomiting What’s your differential diagnosis? • Pain begin in RUQ, progressively worse, subjective chills • Meds – insulin, ASA • Pertinent hx – NH resident, diabetes
  36. 36. Gallbladder Carcinoma pathology • 0.5-1% of pop with cholelithiasis • Poor prognosis (unless T1a) • Most adenocarcinoma • Contracted (nondistended) • Risk Factors: adenomatous polyps, porcelain gallbladder (50%), biliary anomalies
  37. 37. Gallbladder Carcinoma treatment • Localized (lamina propria) • Cholecystectomy • Advanced Stage • radical cholecystectomy • Gallbladder + hepatic segments 4b & 5 + LND
  38. 38. Mirrizzi Syndrome pathology Common hepatic duct obstruction 2/2 impacted stone in cystic duct
  39. 39. Biliary Dyskinesia pathology • Impaired GB emptying or sphincter of Oddi relaxation • Biliary colic (post-prandial sharp RUQ pain), nausea • NO gallstones • Extensive w/u • HIDA + CCK • GB ejection fraction 35% or less
  40. 40. Acalculous Cholecystitis pathology • Seen in critically ill pt • Trauma • Burn • Prolonged TPN or NPO status (weeks) • Cardiopulmonary bypass • Often progress to gangrene or emphysematous cholecystitis • Fulminant course - has 40% mortality rate
  41. 41. Imaging in Gallstone Ileus Imaging

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