Anda di halaman 1dari 61

Gallstones and

Biliary Emergencies
Shawn Hancock, DO
January 6, 2015

Goals/Objectives
Review background on gallstone formation and
epidemiology
Recognize and differentiate between different
biliary emergencies
Summarize the most important pieces of history
and data to synthesize the case and convey
information to colleagues, consultants, surgeons,
etc.
Compare the usefulness and appropriateness of
different imaging studies for the biliary tree and
apply them to the correct clinical scenario

Biliary Emergencies
Acute cholangitis
Acute cholecystitis
Bile Leak
Miscellaneous

Case 1

45 yo F w/ intermittent RUQ pain for ~2 weeks


Now eyes and skin are yellow for last 2 days
No past medical history; her mom had gallstones
On exam: Afebrile, VSS, jaundiced but appears
well, no distress, abd mildly tender in epigastrum
w/o R/R/G
Labs: Tbili 4.2; Alk Phos 451; AST 160; ALT 89;
Lipase 33; WBC 8.2
US: Stones in GB, no GB wall thickening or
pericholecystic fluid, no stones seen in CBD, CBD
measures 9mm

Case 2

55 yo F with RUQ pain and fever x 2 days


PMHx significant for DM, obesity
On exam: T 38.3, HR 100, BP 130/85
Abd: soft, tender in epigastrum, no R/R/G
Labs: Tbili 1.8; AST 190; ALT 95; Alk Phos
190; lipase 40; WBC 12.5
US: Stones in gallbladder, no GB wall
thickening or pericholecystic fluid, CBD
measures 5mm

Case 3
65 yo M veteran w/ abdominal pain x 4 days.
Family found him jaundiced and lethargic
PMHx: extensive
Exam: T 39.1, HR 120, BP 90/50, altered mental
status, abd very tender with guarding, no
rebound
Lab: Tbili 5.1; AST 230; ALT 200; Alk Phos 550;
lipase 100; WBC 19.5
US: Stones in gallbladder, GB wall thickened, +
pericholecystic fluid, + Murphys, CBD measures
1cm

Case 4
27 yo F w/ RUQ pain and fever x 2 days
Recently gave birth to first child
Exam: T 38.3, HR 100, BP 120/80, very
tender in RUQ w/ guarding
Labs: Tbili 0.8; AST 60; ALT 45; Alk phos
120; lipase 20; WBC 19
US: stones in GB, + pericholecystic fluid, +
GB wall thickening, + Murphys sign, CBD
3mm

If you can differentiate the subtle differences


between these 4 cases, youre golden

Background and Epidemiology


Cholelithiasis
Affects 10-14% of general population
16-20% of pts become symptomatic or develop
complications over 10-15 yrs
Approximately 600,000 cholecystectomies per year

Complications

Biliary Colic
Cholecystitis
Pancreatitis
Choledocholithiasis w/ or w/o cholangitis
5-20% of pts will have CBD stones at time of cholecystectomy

Rare: Gallbladder cancer, gallstone ileus

Background and Epidemiology


Fat, Female, Fertile, Forty
Age
Higher rates of cholecystectomy in pts >40yrs old

Sex
Higher prevalance in women, 2.9 to 1 if age <40
Gap narrows w/ age, 1.2 to 1 by age >60

Pregnancy
Prevalance:
1.2% in Nulliparous women
12.2% in Multiparous women

Obesity

Background and Epidemiology


Fat, Female, Fertile, Forty continued
Obesity

Background and Epidemiology


Other Risk Factors
Family History
2-5 times more common amongst 1st degree
relatives than matched controls

Rapid weight loss


Gallbladder stasis (TPN)
Diabetes mellitus
Cirrhosis
Crohns disease

Biliary Emergencies
Acute cholangitis
Acute cholecystitis
Bile Leak
Miscellaneous

Ascending Cholangitis
Bacterial infection of an obstructed biliary tree - closed
space infection
If untreated has significant morbidity and mortality
Obligatory pimp questions on:
Charcots triad
Reynolds pentad
Medical emergency with T>40, TB>10, sepsis,
hypotension, or peritoneal signs

Etiology of Acute Cholangitis

Choledocholithiasis - > 80%


Strictures
Malignancy
PSC
Recurrent pyogenic cholangitis
Choledochocoele

Diagnosis of Acute Cholangitis


Clinical presentation
Labs
LFTs can elevate for a variety of reasons-including cholecystitis
The higher the bilirubin, the higher the chance of CBD stones

Common bile duct dilation on imaging


US, CT, MRCP
Larger the CBD, the higher the chance of choledocholithiasis
5mm is upper limit of normal if GB is still in place, allow extra
1mm per decade of life above age 50
But beware, acute obstruction and lack of dilation

Treatment of Acute Cholangitis


IVF, NPO, broad spectrum antibiotics
make sure gram (-) organisms are covered
Unasyn or Cipro/Flagyl usually adequate

85 % of patients will respond and


decompression of the biliary system can
be performed on a semi-elective basis
15 % will not respond and need
urgent/emergent decompression

Treatment of Acute Cholangitis


ERCP (preferred)
Percutaneous
Surgical
Successful in 90%; morbidity rate 30-80%
CBD exploration, T-tube drainage, biliaryenteric anastomosis
High mortality for urgent decompression 2060%

Biliary Emergencies
Acute cholangitis
Acute cholecystitis
Bile Leak
Miscellaneous

Acute Cholecystitis
Most frequent complication of gallstone disease
Transient or permanent obstruction of the cystic
duct in over 90% of cases
Obstruction leads to distension, increased
intraluminal pressure, and inflammation of the
gallbladder wall (mucosal ischemia)
Bacterial infection is a secondary event
E.coli, Kliebsiella, Streptococcus, and
Clostridium

Diagnosis

Diffuse abdominal pain RUQ/epig


Acute onset of nausea, vomiting, fever
Signs of localized tenderness/peritonitis
Murphys sign
Leukocytosis with left shift
Mild elevation of bilirubin, AST, ALT, Alk
phos

Gallstone disease

Diagnosis
Ultrasound - wall thickening, distension,
sludge/stones, pericholecystic fluid, sonographic
Murphys sign sensitivity and specificity 88 and
80% respectively
Radionuclide scintigraphy - sensitivities and
specificities greater than 90-95 %
Caution: liver disease, hyperbilirubinemia, prior
sphincterotomy

CT scan
Can be useful, but largely unnecessary when looking
for cholecystitis

Treatment
Fluids, NPO, analgesics, antibiotics

Surgery
Early
Open versus laparoscopic

Percutaneous cholecystostomy

Complications:
10-30%
Gallbladder gangrene, perforation,
empyema
Cholecystoenteric (biliodigestive) fistula
<1%
-Aerobilia
Mirizzi syndrome

Acute Acalculous
Cholecystitis
Critically ill patients:
- Trauma, surgery , burns, TPN

Pathogenesis debated:
- Bile stasis
- Cholecystoparesis
- Gallbladder ischemia
- Bacterial colonization

Mortality can be as high as 90% in critically ill


- Delay in diagnosis, perforation
- Older patients, leukocytosis correlated with poor outcome

Acalculous Cholecystitis

Symptoms identical to calculous cholecystitis or more subtle


US, CT, HIDA with good sensitivity

US findings: NO stones, GB wall>5mm, endoscopic Murphys, failure to see GB,


emphysema, perforation

HIDA has limitations (boards trick on false negatives)


- Severe liver disease
- Fasting patients on TPN (GB full)
- Good biliary sphincterotomies
- Hyperbilirubinemia (newer agents overcome this)

Treatment
Percutaneous cholecystosomy
Cholecystectomy

Biliary Emergencies
Acute cholangitis
Acute cholecystitis
Bile Leak
Miscellaneous

Bile Leak
Bile leaks from the gallbladder/biliary
system into the abdominal cavity
Bile is initially sterile but secondary
infection may occur with marked
deterioration in condition
Etiology
Post cholecystectomy (0.5-1%)
Gangrene of gallbladder, trauma, liver biopsy,
ERCP, surgery

Bile Leak
Diagnosis
Severe abdominal pain, intra-abdominal fluid
collection, possibly peritonitis and shock
CT or US can confirm fluid collection
(Occasionally fluid it tapped, can be diagnostic)

HIDA confirms bile leak


ERCP makes definitive diagnosis (and
provides therapy)

Bile Leak
Treatment
Antibiotics, NPO
Endoscopic
Transpapillary stent
Sphincterotomy

Percutaneous
Surgery

Biliary Emergencies
Acute cholangitis
Acute cholecystitis
Bile Leak
Miscellaneous

Post ERCP Pancreatitis


Most common complication of ERCP
Range 2-15% (~5% is probably most
accurate)
(Patient) Risk Factors:
Young females
Normal bilirubin, non dilated CBD
SOD pts
Recurrent pancreatitis
History of post-ERCP pancreatitis

Post Sphincterotomy Bleeding


Next most common complication of ERCP
Occurs 1-2% of the time
Fortunately, rarely causes significant
morbidity/mortality
Treat with epinephrine injection
(rarely hemoclips or cautery)

Review of Imaging the Biliary


Tree

Review of Imaging the Biliary


Tree
US
Sens/Spec 88/80% for cholecystitis
Sens/Spec 84/99% for detecting GB stones
Poor sensitivity for seeing CBD stonesBUT,
excellent at getting measurement of CBD

CT
Can be useful, but usually unnecessary for
diagnosis of cholecystitis, choledocholithiasis,
or cholangitis

Review of Imaging the Biliary


Tree
MRCP
Sens/Spec 93/94% for CBD stones
Sensitivity decreases for small stones

EUS
Sens/Spec 94/95% for CBD stones
More sensitive for small stones, can detect
sludge too

Review of Imaging the Biliary


Tree
HIDA Scan
Sens/Spec 97/90% for cholecystitis
Can be used to confirm diagnosis of bile leak

Intraoperative Cholangiogram
Highly sensitive/specific for CBD stones
Useful in cases of low suspicion for CBD stones and going
to OR anyway soon for lap chole

ERCP
Gold standard for cholangitis, choledocholithiasis, bile
leaks.
Truly a therapeutic procedure for the above conditions
more than a diagnostic test

Back to Cases

Case 1

45 yo F w/ intermittent RUQ pain for 7 days


Now eyes and skin are yellow for last 2 days
No past medical history; her mom had gallstones
On exam: Afebrile, VSS, jaundiced but appears
well, no distress, abd mildly tender in epigastrum
w/o R/R/G
Labs: Tbili 4.2; Alk Phos 451; AST 160; ALT 89;
Lipase 33; WBC 8.2
US: Stones in GB, no GB wall thickening or
pericholecystic fluid, no stones seen in CBD, CBD
measures 9mm

Case 2

55 yo F with RUQ pain and fever x 2 days


PMHx significant for DM, obesity
On exam: T 38.3, HR 100, BP 130/85
Abd: soft, tender in epigastrum, no R/R/G
Labs: Tbili 1.8; AST 190; ALT 95; Alk Phos
190; lipase 40; WBC 12.5
US: Stones in gallbladder, no GB wall
thickening or pericholecystic fluid, CBD
measures 5mm

Case 3
65 yo M veteran w/ abdominal pain x 4 days.
Family found him jaundiced and lethargic
PMHx: extensive
Exam: T 39.1, HR 120, BP 90/50, altered mental
status, abd very tender with guarding, no
rebound
Lab: Tbili 5.1; AST 230; ALT 200; Alk Phos 550;
lipase 100; WBC 19.5
US: Stones in gallbladder, GB wall thickened, +
pericholecystic fluid, + Murphys, CBD measures
1cm

Case 4
27 yo F w/ RUQ pain and fever x 2 days
Recently gave birth to first child
Exam: T 38.3, HR 100, BP 120/80, very
tender in RUQ w/ guarding
Labs: Tbili 0.8; AST 60; ALT 45; Alk phos
120; lipase 20; WBC 19
US: stones in GB, + pericholecystic fluid, +
GB wall thickening, + Murphys sign, CBD
3mm

Ultimate Goals
Differentiate:
Presence or absence of biliary obstruction
Choledocholithiasis
Cholangitis
Cholecystitis
Cholecystitis and cholangitis
Passed stones

Most important piece(s) of


information
History
Chronicity/duration of pain; intermittent vs. constant, etc.
Foregut surgeries (Whipple, gastric bypass, Bilroth, etc)

Fevers/vitals
Helps determine urgency
Also think about sedation risks too

Labs
T Bili (and DBili), AST/ALT, Alk Phos, Amylase/Lipase
TREND OF LABS

Imaging
Gallbladder: stones or no stones, cholecystitis or no cholecystitis
CBD: dilated or not dilated, size
? Evidence of pancreatitis

Thank You
Questions/Discussion