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. • 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
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. 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%
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. 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. 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
26. 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
27. 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
28. 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?
29. 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
31. Diagnosis
diagnosis
• History & physical exam
• Ultrasound
• 95% sensitive
• Hyperechoic mobile densities within gallbladder
with assoc hypoechoic shadowing
32. 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?
36. 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
37. 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
40. 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
41. 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