Gallstones!
What are the two presentations of gallstone disease?
There are multiple presentations of gallstone disease. Broadly, the presentations can be thought of as two conditions and their complications:
-Cholelithiasis (gallstones in the gallbladder)
-Choledocholithiasis (gallstones stuck in the common bile duct)
What causes gallstone pancreatitis?
Gallstone that migrates through the common bile duct to the ampulla of vater can lodge where the pancreatic duct meets the ampulla and the pancreatic duct can be occluded preventing the release of pancreatic juices and enzymes which begin to autodigest the pancreas
Pathophysiology of gallstone ileus
Rare complication of chronic cholecystitis where chronic inflammation can lead to a fistula between the gallbladder and the GI tract, a large gallstone can pass through the fistula into the GI tract and become lodged at the ileocecal valve and cause intestinal obstruction
In acute pancreatitis, name the lab tests necessary to determine volume status and sufficient tissue perfusion
1. BUN - BUN may be increased in acute pancreatitis due to the leakage of activated enzymes like trypsin and chemotrypsin, as well as inflammatory mediators and cytokines. Acute renal injury can also simultaneously occur via a reduction in intravascular volume, also leading to an increased BUN
2. Hematocrit - helps determine fluid replacement in critically ill patients and also correlates with the development of pancreatic necrosis. The higher the hematocrit, the more increased your hemoconcentration, which means the thicker your blood, the lower your plasma volume, and the higher chance of organ failure
3. Creatinine
4. Lactate - marker of tissue hypoxia and unstable hemodynamics
What does ERCP stand for?
Endoscopic retrograde cholangiopancreatography
Approximately ___% of people form gallstones most of these patients present with ___ symptoms. Fill in the blanks
Approximately 20% of people form gallstones. Most of these patients will be asymptomatic. In a minority of people, gallstones migrate to obstruct a bile duct, and in those cases, there will be symptoms.
In ascending cholangitis, what three symptoms make up charcot triad?
Jaundice, fever, and RUQ pain
What are the imaging result of acute cholecysitis?
On ultrasound imaging, the gallbladder often has a thick edematous wall and may show free fluid collecting around the gallbladder. Gallstones may also be seen on ultrasound, though the absence of gallstones doesn’t exclude the diagnosis of cholecystitis.
Describe the clinical presentation for acute pancreatitis (at least 4)
1. Constant, severe epigastric pain
-classically radiating towards the back
-worse after meals and when supine
-improves on leaning forward
2. Nausea
3. Vomiting
4. Feverr
5. If pulmonary complications present, chest pain and dyspnea
What are the indications of emergent cholecystectomy?
Hx of gallstones with complications like gallstone pancreatitis and obstructive jaundice
Cholecystitis
Acute RUQ pain
Fever
Leukocytosis
Concerns for gangrene or perforation
Biliary dyskinesia-hypofunction
Ascending cholangitis
What are the four “Fs” of gallstones?
Female, Fertile (pregnancy), Fat (overweight), Forty
What is the pathophysiology of ascending cholangitis and what bacteria are implicated?
Bile duct is obstructed usually by a gallstone (choledocholithiasis) ---> bile flow stagnates ie cholestasis making biliary tract susceptible to infection from bacteria found in the GI tract like E. coli, Klebsiella, and Enterococcus spp, and anaerobes which ascend through through the sphincter of oddi into the ampulla of vater and ascend the biliary tree
What are the imaging results of chronic cholecystitis?
The chronic inflammation of the gallbladder leads to diffuse thickening and calcification of the gallbladder wall that can be seen on imaging as a “porcelain gallbladder.”
Describe the Cullen Sign, Grey Turner Sign, and Fox Sign
Cullen sign: periumbilical ecchymosis and discoloration (bluish-red)
Grey Turner sign: flank ecchymosis with discoloration
Fox sign: ecchymosis over the inguinal ligament
In pancreatitis, aside from fluid replacement as a treatment, what other treatment is safe and effective?
Opioids are safe and effective
Suggested medications are fentanyl or hydromorphone
Fentanyl is being used more as it more safe compared to other opioids but still has risk for respiratory suppression, dosage is 20-50 micrograms
What lab results are associated with choledocholithiasis?
Gallstones block the common bile duct leading to cholestasis, can be seen on labs as having ALP higher than ALT or AST with an increase in conjugated (direct) bilirubin, US shows dilated common bile duct
What disease results from fulminant ascending cholangitis and what symptoms are associated with it?
Suppurative cholangitis is a more complicated and advanced case of ascending cholangitis, develop confusion or hypotension due to septic shock, Charcot triad with the addition of these two symptoms is known as Reynolds pentad. Both are signs of a fulminant (escalating) form of the disease with more generalized spread throughout the circulation.
Provide the mechanism of action for Ursodeoxycholic acid (ursodiol) and provide the rationale as to why this treatment is not recommended
Naturally occuring bile acid, makes up about 5% of bille,therefore if we supply a bile acid which can go to a bile salt which will reduce the level of cholesterol, it is actually considered a Cholelitholytic agent meaning that it will dissolve the cholesterol
This treatment is not recommended as it takes two years of use to dissolve stone and is not found to be very effective.
In acute pancreatitis, IV fluid resuscitation is a fundamental component of initial supportive treatment in order to reduce morbidity and mortality. Why?
The goal of fluid resuscitation is to restore blood volume deficiency, improve tissue perfusion, increase cardiac output, increase capillary permeability stabilization, modulation of the inflammation reaction, and restore the intestinal barrier function
Up to ______ of patients will develop a ________ due to changes in permeability of gut and vasculature and suppression of immune system.
*Looking for a percentage and complication, respectively*
Up to 20% of patients will develop a extrapancreatic infection (blood, pneumonia, UTI) due to changes in permeability of gut and vasculature and suppression of immune system
3 main pathways of gallstone formation
Cholesterol supersaturation: Normally, bile can dissolve the amount of cholesterol excreted by the liver. But if the liver produces more cholesterol than bile can dissolve, the excess cholesterol may precipitate as crystals. Crystals are trapped in gallbladder mucus, producing gallbladder sludge. With time, the crystals may grow to form stones and occlude the ducts which ultimately produce the gallstone disease.
Excess bilirubin: Bilirubin, a yellow pigment derived from the breakdown of red blood cells, is secreted into bile by liver cells. Certain hematologic conditions cause the liver to make too much bilirubin through the processing of breakdown of hemoglobin. This excess bilirubin may also cause gallstone formation.
Gallbladder hypomotility or impaired contractility: If the gallbladder does not empty effectively, bile may become concentrated and form gallstones.
What lab results indicate ascending cholangitis?
Labs show increased WBC and cholestatic elevation of LFTs (ALP, direct bilirubin, and γ-glutamyltransferase), imaging can be done with US, CT, and MR cholangiography showing biliary dilation and often its etiology, usually a gallstone. If an ERCP is done because of severe illness, the infected bile can be directly cultured
What 3 inflammatory mediators are involved in acute pancreatitis and how do their MOAs result in fluid flow?
Acute pancreatitis is caused by organ failure due to excessive inflammatory mediators and the systemic inflammatory response. TNF-a, IL-6, and IL-8 in particular injure the microcirculation endothelium, which increases the permeability of the vasculature.
This leads to transudation of fluid from the intravascular space to the interstitial space, resulting in capillary leakage syndrome and multiple organ dysfunction syndrome.
Name three risk factors for cholangiocarcinoma
1) Inflammation and cholestasis (bile flow obstruction) seen in these conditions lead to cholangiocarcinoma because the constant inflammation of the bile duct cholangiocytes leads to epithelial cell transformation into cancer.
2) primary sclerosing cholangitis- A chronic scarring disease of the liver and biliary tree seen in some patients with inflammatory bowel disease
3) Clonorchis sinensis (Chinese liver fluke) infection: A parasitic flatworm common to Asia and Russia
4) Thorotrast: A contrast dye used until the 1950s
5) Choledochal cysts: Rare congenital dilations of the bile ducts
Name three prophylactic antibiotics that can used to treat pancreatitis
Prophylactic antibiotics include: carbapenem alone, or a quinolone, ceftazidime, or cefepime combined with gram anaerobic coverage metronidazole