Name that disease
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.
Acute cholecystitis - persistent obstruction of the gallbladder
What is the tx for a patient with asymptomatic cholelithiasis?
Observation
Murphy sign
Acute cholecystitis
MC type of gallstone?
cholesterol
Best initial test for acute cholecystitis?
RUQ U/S - will show wall thickening, pericholecystic fluid, and sonographic Murphy's sign
A 48-year-old woman presents to the emergency department with severe right upper quadrant abdominal pain that began suddenly 6 hours ago. She reports nausea and several episodes of vomiting. The pain radiates to her back and right shoulder and is worse after eating a fatty meal last night. She has a history of gallstones but has not had surgery. On exam, she is febrile to 38.3°C (100.9°F), blood pressure is 122/78 mmHg, and pulse is 96/min. Scleral icterus is present. Abdominal exam reveals tenderness in the right upper quadrant without rebound or guarding. Laboratory studies show:
AST 135 U/L (↑)
ALT 150 U/L (↑)
Alkaline phosphatase 450 U/L (↑↑)
Total bilirubin 5.2 mg/dL (↑)
Ultrasound demonstrates dilated intrahepatic and extrahepatic bile ducts, but the gallbladder wall is normal without pericholecystic fluid.
Choledocholithiasis - gallstones in common bile duct leading to cholestasis
What is the tx for a patient who is symptomatic with cholelithiasis?
Elective laparoscopic cholecystectomy
Porcelain Gallbladder
Chronic cholecystitis
MC secondary infectious cause of acute cholecystitis?
E. coli
Gold standard for diagnosis and tx of choledocholithiasis?
A 55-year-old woman presents to her primary care clinic with several months of intermittent right upper quadrant abdominal pain. The pain typically occurs after large or fatty meals and lasts 1–2 hours before resolving on its own. She denies fever, chills, or jaundice. She has had multiple similar episodes over the past year but has not sought care until now. Her past medical history includes obesity and type 2 diabetes. On physical exam, she is afebrile with normal vital signs. Abdominal exam reveals mild right upper quadrant tenderness without guarding or rebound. Laboratory studies show normal liver function tests and normal white blood cell count.
An abdominal ultrasound shows a thickened gallbladder wall with multiple gallstones but no pericholecystic fluid or biliary ductal dilatation.
Chronic Cholecystitis
What is the tx for acute cholecystitis if the pt is not a candidate for surgery?
Charcot's Triad/Reynold's Pentad
Acute ascending cholangitis
MCC of chronic cholecystitis?
Gallstones
What lab abnormalities will be seen in a pt with acute ascending cholangitis? (3 different ones)
1. leukocytosis
2. Elevated LFTs
3. + culture for organism
A 39-year-old man presents with progressive fatigue and pruritus over the past 6 months. He also reports intermittent right upper quadrant abdominal discomfort and unintentional weight loss of 5 pounds. His past medical history is significant for ulcerative colitis diagnosed 8 years ago, currently managed with mesalamine. On physical exam, he has mild hepatomegaly and jaundice.
Laboratory studies reveal:
Total bilirubin: 3.1 mg/dL (↑)
AST/ALT: mild elevation
p-ANCA: positive
Magnetic resonance cholangiopancreatography (MRCP) demonstrates multifocal stricturing and dilatation of intrahepatic and extrahepatic bile ducts, producing a “beaded” appearance.
Primary sclerosing cholangitis - autoimmune diffuse inflammation of biliary tract leading to segmental fibrosis
What is the tx for a patient with choledocholithiasis? What prevents recurrence definitively?
ECRP stone extraction
Cholecystectomy prevents recurrence
Boas sign
Acute cholecystitis
MC symptom associated with choledocholithiasis?
Prolonged biliary colic
What is the gold standard diagnostic method for primary sclerosing cholangitis? What will it show? What should be done if it is inconclusive?
Gold standard = MRCP showing alternating fibrosis
If inconclusive, order ERCP
A 62-year-old man presents to the emergency department with sudden-onset right upper quadrant abdominal pain, fever, and jaundice for the past 12 hours. He also reports nausea and confusion. His past medical history includes gallstones. On physical exam, his temperature is 39.2°C (102.6°F), blood pressure is 88/52 mmHg, heart rate is 120/min, and he appears ill and diaphoretic. He has scleral icterus and marked right upper quadrant tenderness.
Laboratory studies show:
WBC count: 15,500/µL (↑)
Total bilirubin: 6.8 mg/dL (↑↑)
AST/ALT: mild elevation
Acute ascending cholangitis - obstruction of common bile duct leading to biliary tract inflammation and infection moving up the biliary tree
*Reynold's Pentad, leukocytosis
What is the tx for a patient with acute ascending cholagitis?
IV Ceftriaxone and Metro or Flagyl
+
ERCP
Periductal fibrosis ("onion skinning") on histology
MCC of acute ascending cholangitis?
Choledocholithiasis
In a patient with chronic cholecystitis, what diagnostic method should be used if an U/S is not diagnostic? What will it show?
HIDA scan - will show decreased gallbladder EF