Cram The Pance - S1E9 Biliary Disorders

Episode Date: January 24, 2021

Cholecystitis, Cholangitis, Choledocholithiasis, Cholelithiasis review for your PANCE, PANRE, and EOR’s.►Paypal Donation Link: https://bit.ly/3dxmTql--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right. So we're going to be going over biliary disorders. That's colylothiasis, colisestitis, colidocelithiasis, and colangitis. So let's start with one of the more simple ones. That's going to be coli litheisis. So this is pretty much there's a gall stone in the gallbladder, but it's not causing any problems. There's no inflammation. There's typically not an infection. So this basically just means gallstone usually just sitting in the gallbladder, not normally causing any problems. What you need to know for this is that there's a few different types of gallstones that are present in patients. Your most common by far, about 80% of gallstones are cholesterol gallstones. There are going to be yellow, green, and about 80% of the gallstones that you're going to see in

patients. There's a couple other different kinds. There's brown stones, which is typically from a bacterial infection, whether it's parasitic, bacterial in nature. Brownstones are normally going to be infection. There's also black stones, and these are normally, seen with alcoholic patients with cirrhosis or hemolysis. So blackstones are more related to that. And this is normally a more sterile bile, not normally from infectious causes. But the one you really need to know is cholesterol because that's going to be the majority of patients. Now, as far as risk factors for golf stones for coliothiasis, there's the five Fs, but really it's the four Fs because one of these has kind of been taken away over the years because it was found not to be too true. So as far as the

four Fs that you need to know, it's fast. BMI over 30 predisposes, gives you a higher risk of gallstones. Female, two to three, two to three times higher in women. You'll see gallstones about two to three times more prevalent in women. 40, because this is the age premenopausal, hormonal changes. These hormonal changes puts you at an increased risk for gallstones and then fertile. So multiple pregnancies. Pregnancy itself, actually, because of all the increase in hormones and estrogen,

can increase your risk for gallstones. The fifth one that isn't really so relevant anymore used to be fair. It used to mean like Caucasian fair skin. But research is shown over the years that this is actually more common in Native Americans and Hispanic. So fair is kind of out of the five Fs. And now it's really the four Fs, which is fat, female, 40, fertile. So those are going to be a risk factor. And remember, look for that in the vignette.

Remember, those are like the key things you need to look for in your vignette for a patient with gallstones or chlorophystiasis. Another thing that I wanted to touch on too is weight loss. And there's a bit of a misconception that losing weight itself causes, predisposes patients to gallstones. But that's not actually the case. So it's not the weight loss that predisposes. It's actually the decrease in fat intake. So every time you eat a fatty meal, the gallbladder has to contract and it has to squeeze out the bile. So when you're eating decreased fat, you're eating decreased food, you have this billiary stasis. You have the stagnant bile because it's not actually contracting as much anymore. So when this bile becomes stagnant, it actually saturates.

It's supersaturation and the super saturation of bile due to the decrease of use leads to stone. So it's more so the decrease in fat and the decrease in food intake that predisposes patients that are losing weight to gallstone. So remember that as well. As far as the patient presentation and the symptoms, a lot of these patients are going to be asymptomatic. and it may just be found incidentally on an ultrasound or another imaging study. But they do have something called billiary colic, which is this sudden, most of the time short-lived about an hour or two of right upper quadrant pain. So what happens in these patients is they have a stone in the gallbladder, just sitting

in the gallbladder, not causing any problems. And then they eat a fatty meal, something that causes the gall-bladder to contract, which can push the stone into the neck of the gall-bladder, blocking the cystic duct. and so temporarily blocking this area and it can lead to pain. So these are called billiary colic. And again, they're short-lived. And a lot of times patients won't have them at all. But if they do have pain, this is normally what's happening.

The gallbladder contracts after the fatty meal, but then it normally relaxes. And the stone kind of pushes its way back into the gallbladder and not causing any more problems after that. So really that's the only symptom you'll see in these patients. As far as diagnosis, you're going to see a trend here with all these billiary conditions. Ultrasound is almost always going to be your first line. So diagnosis for this ultrasound, it's normally. all you need to do to visualize the stones or see where they're sitting in the in the gallbladder.

And then you can get labs, serum LFTs. Most of the time they're going to be normal. So if you did happen to see an increase in alkaline phosphatase, it can indicate an obstructive cystic or bile duct. But most of the time labs aren't going to be very useful here. And ultrasound would probably be the only thing that you're going to need to do. As far as treatment, if they're asymptomatic, just observe. You do have the option of a colisisosectomy. if the patient became symptomatic or in asymptomatic patients who have an increased risk of developing gallbladder carcinoma. And there's something called porcelain gallbladder, which is a calcified gallbladder.

And these patients are at a much higher risk of gallbladder carcinoma. So those types of patients you might want to do a coliseostectomy, which would be removing the gallbladder. But otherwise, most of the time, asymptomatic patients you're just going to observe. And as long as they're not having any problems, just kind of leave them alone. So moving on, so now we went over coli lithosis, which is just those gallbladder sitting in the gallbladder. Now we're moving on to the more problematic gallstone issues. And this is going to be acute colitis. So acute coli cystitis is gallstone obstruction normally in the cystic duct.

So it's blocking the cystic duct, which is what is the outlet for the gallbladder to get bile into the common bile duct. So this is going to be a gallstone obstruction in the cystic duct. Really quick, I do want to mention about 90% of the duclite duct, which is the outlet, which is the outlet. time acute colitis is from gallstones, but there's about 10% where it's not. I'll go over that after pretty briefly, but not too much to know there. There's something called a calculus colisestitis. I'll go over that in a minute, but there's not too much to know there. So most of the time, acute colitisitis, about 90% of the time is going to be caused from a gallstone obstructing the cystic duct. So these patients are going to have this abdominal pain generally in the right upper quadrant.

again, all of these are pretty much right upper quadrant because that's where the gallbladder is. And there's something that you need to know about that pain is pretty important that they're probably going to test you on. There's something called a Boas sign. So B-O-A-S-B-O-A-S-Baw. And that's when the pain from the right upper quadrant actually radiates to the right shoulder or scapula area. Now, why does this happen? Well, you have your phrenic nerve, which innervates the parietal peritoneum, which is right near the gallbladder there. So it overlies the gallbladder. And that phrenic nerve connects all the way up to about C4, C5, and all the way into the shoulder

area, into the neck. So this nerve, the frenic nerve, connects from the bottom of the diaphragm there all the way up to the shoulder. So it's actually sending that referred pain. So these patients may actually come in with right shoulder and right back, right upper back pain. And that's why you're seeing that. It's called Bois sign.

So definitely know that. And then the pain may also present typically after. consumption of fatty meals because again like we went over before the gallbladder is contracting getting out the bile and that's when the stone gets pushed into the cystic duct and you start having these problems so acute colicestitis is inflammation infection of the gallbladder and on physical exam the gallbladder may be enlarged when you're feeling it and there's a sign that you definitely need to know especially for your oskies because this is an important one there's something called a murphy's sign so what a murphy sign is is it's going to be right up her quadrant pain um when you

push up into the subcostal region. So what you do on a Murphy sign is you have the patient take a deep breath out, which pushes the diaphragm up, gallbladder goes up with it. And at that point, you put your fingers under the costal margin, under the ribs on the right side. And then you have them taken a deep breath, which pushes the diaphragm down, pushes the gallbladder into your fingers under there. And as soon as the gallbladder touches your fingers, they're going to kind of jump up and they're going to kind of stop breathing because they're having such pain there. That's called a Murphy's sign. So it's right upper quadrant pain or a sudden cessation of respiration when you're palpating under that right coastal margin. So you need to know that for real life and for your oskies and your

exams as well. So know that physical exam finding. As far as diagnosis, again, this trend you're going to see ultrasound is going to be your initial test of choice. It's going to show it should show gallbladder while thickening. Normally over three millimeters is indicative of acute colitis. You may see the gallbladder distended. And then you also may have a Murphy sign with the sonographic probe. So that's called a sonographic Murphy sign. Same idea pushing under the right upper quadrant. They're going to take in a deep breath and they're going to kind of jump and stop breathing because of that pain there. Now, ultrasound is your initial test of choice. And normally it's enough to diagnose it, but you do have a gold standard, which is going to be your

most accurate test, but obviously more expensive and not always used. And that's a height of scan. So that's, it's a nuclear medicine study where they inject radioactive tracer IV and the radioactive tracer through an IV. And the radio tracer, if it's not visualized or these patients have decreased ejection fraction of this radio tracer, that indicates that the gallbladder is inflamed. And this is a positive study. So you give them something, give them a radioactive tracer. and then you give them this medication called Kinovac, which stimulates the gallbladder, makes it contract. And if you're not seeing this ejection from the gallbladder when it's contracting, that means that it's blocked by a stone, and that's a positive hyda scan. So that's something else you need

to know. That's going to be your gold standard. So again, you're not always going to use it, but if you really say the ultrasound came out negative and you're really convinced this patient has, colisestitis, you can also do a height of skin. So that's your gold standard. As far as treatment, this is going to be another common theme you're going to see here, colisisestectomy. That's going to be your go-to, and that colisestectomy is going to be removing the gallbladder entirely, so you eliminate the problem. But initially, when you have a patient with acute coliscystitis, before you go to colisestectomy, before you bring them over to surgery, you want to stabilize them first, make sure they're not febrile, give them IV fluids, antibiotics. So supportive treatment

before you throw them into the OR. As far as the antibiotics, with acute colise, holiesocytis, you're normally going to see E. coli is going to be your most common organism and other gram-negative organisms. So you're going to treat these patients with pretty broad spectrum antibiotics that's going to cover your gram-negatives, your anterococcus. So ampacillin solbactin, which is unison, is one of your first lines, septriaxone, metronidazol. Again, you're having your gram-negative coverage and your anaerobic with the metronidazole, your gram-negative with the septriaxone. So you're going to have these broad spectrum antibiotics that you can use. Erdipenum is another one that you can use. Again, that covers your gram-negative and your anorokes. So if you do give them antibiotics to stabilize

them, get them a little bit better before surgery, you're going to use these broad spectrums, ampaclysmolentacin-so-backum, septriaxometrinitisol, erypenum are some of the top ones that you can use. Now, if these patients are not, you know, if they're non-surgical candidates, or you need to delay surgery, if there's a suspected gangrene perforation, and the patient isn't ready for a colisosectomy, you can do something called a coli cystotomy, which is percutaneously draining the infected gallbladder. So it's this thin, hollow, flexible tube you place in the gallbladder, and it drains all of the bile and all of the infected fluid out before you remove the gallbladder and do a coliocyctomy. So that's non-surgical candidates, patients that are really sick that may have, you know,

green or perforated gallbladder. That's what you would do first in those patients. But generally, colisisestectomy is going to be your go-to treatment for patients with acute colisestitis. So one thing that I wanted to really briefly touch on, this isn't very high yield, but there is something called acute acalculus colisestitis. So this is going to be a colisestitis not caused from a gallstone. It's not very common, maybe about 10% of patients with acute coli-sistitis present with this acalculus, so not from a gallstone. colisestitis, and it's really only seen in critically ill hospitalized patients. So it's due to ischemia and stagnant gallbladder stasis. The stagnant bile, these patients aren't eating,

they're sick, is not being excreted and it leads to the stagnant bile leads to infection, necrosis. So you're only going to see this in really sick patients. You're not going to have somebody coming in off the street with a calculus colisitis. These are basically hospitalized sick patients. Diagnosing, again, ultrasound and treatment really is just support. portive, IV fluids, pain control, antibiotics. So not too much to know there, but I just wanted you to know that that is something that exists, just so you know that for, for clinicals and things like that. It can, colitis can be caused from a non-golbladder cause, and that's a calculus coliocytitis, just so you know that one. So moving on, we're going to do, you know,

moving down the billiary tree here, we're focusing on the gallbladder and stones in there. And let's move on to coli-dokal. lithiasis. So coli lithiasis is when the stone was in the gallbladder. Now colidocelithiasis is when the stones are in the common bile duct. So now the stone's a little bit further down. It can be a little bit more problematic because now you're not just blocking the gallbladder. Now you're actually blocking both the gallbladder and the liver because you're in that common bile duct, which is shared by the gallbladder and the liver. This can cause some more problems. So patient again is going to present with a right-up or quadrant pain. They may have some epigastric pain. But now the difference is because

the stone is in the common bile duct, now they may also have jaundice because now the stone is blocking the flow of bile from the liver. This buildup of Billy Rubin can, you know, back up into the bloodstream and you're going to have these patients appearing yellow and with jaundice. So remember that they're going to have this, you know, painful right-upor quadrant pain and jaundice as well because the location of the stone is now affecting the liver. And remember, pain and jaundice, as bad as that sounds, but is actually a good thing because if you have painless jaundice, they present with jaundice, but they don't have any right up or quadrant pain, nothing else is going on. Normally, that's indicative of pancreatic cancer. So pain and jaundice is good, painless jaundice.

Normally it's a bad sign because this is normally caused from a pancreatic carcinoma. So that's something you should know too for physical exam findings. Now with colidocytocysis, diagnosis again, what do you think is going to, what do we think we're going to use ultrasound? So you want to see where the stone's located. And now your labs are a little bit more important. They weren't so important before, but now you do have some labs that you want to take a look at because again, remember the liver's involved. So in these labs and these patients, you may see an increased AST and ALT. Your alkaline phosphatase may be elevated. Your GGT, these are all liver enzymes. These are all going to be elevated. Your GGT, some people aren't that familiar with that one. That's your gamma glutamil transferase. And it's found in high concentrations. concentrations in the liver. And when it's elevated, it can indicate some kind of liver injury or trauma. That's a more specific lab for the liver because alkaline phosphatase can be not necessarily that specific to the liver.

So you're going to see all of these increased in these patients a lot of the time. And remember that liver enzymes can be increased due to a number of reasons. So like I said before, it's not always a specific test, but it's really good at ruling something like colidococytosis out. So if these are elevated, it doesn't necessarily 100% mean that there's a stone there. But if they're negative, there's a very small chance that this patient has colidocelethiasis. So it's more, it's better for ruling something out. So remember, the liver enzymes aren't 100% specific, but they are good at ruling something like this out. So remember that in colidocelotithiasis, you're going to see some of those liver enzymes normally elevated. As far as, it's really both the diagnosis and treatment, you can do something

called an ERCP, which is endoscopic retrograde colangio pancreatography. This is basically you're putting a camera into the duodenum. You're entering through the sphincter of odi, which is the end of the common bile duct that empties out into the duodenum. So you're going in through that sphincter of odi, and you inject contrast into the common bile duct. So when you inject the contrast, if all of a sudden you see the contrast abruptly stop and you visualize this blockage, you know that there's stone there. And what you do, so now you're able to visualize the stone, but you now you can also treat these patients as well with an ERCP. So you have the camera in there. What they do from here is they actually have a small tool within the ERCP where they can

bur a small hole into the stone. They can kind of latch on through the hole and they blow up this small balloon and they pull it out and they pull it out into the doodum so it can just be digested and flushed out of the body. So that's an ERCP. And ERCP can, can both diagnose and treat colidocelithiasis, and this is one of your first-line treatments for these types of cases. So if an ERCP is unsuccessful, another option is laparoscopic colidocletotomy, which is, of course, more invasive. It's surgical procedure. So an ERCP, if possible, is going to be preferred. So that's colidocelithiasis. Let's move on to something a little bit more severe. This is going to be acute colinitis. So now you have the,

same obstructing stone like you did in colidocelothiasis, but in this case, you have biliary stasis due to the stone, and the stagnant bile can lead to this ascending infection. So the obstruction doesn't always have to be from a gall stone with acute colangitis. Sometimes it can be due to a malignancy in the common bile duct, but in most cases, it's going to be due to a more rare cases it can also be due to iatrogenic causes like an ERCP. but most cases acute colonitis is going to be from a stone which leads to this biliary stasis and this stagnant bile leads to this ascending infection. So this can be pretty severe in a lot of patients. Some of the etiologies, the most common bacteria is going to be colonic origin. So e coli, by far is going to be your most common. Clubsiella is a pretty close second. And then enterobacter

species is another, you know, about third in line. But most common is going to be your E. coli. it's going to be the most common organism isolated in acute colangitis. So how is this patient going to present? Well, now you have some of your key terms for the boards that they like to use. So you have something called Charcos Triad and you have something called Reynolds Pentat. Remember these. I remember them always coming up in school. You should know these.

It's just one of these things that you should know very well. So in a patient with acute colinjitis, Charcos triad is going to be fever, abdominal pain, and jaundice. that abdominal pain is normally, of course, right up or quadrant. But remember, for real life, Sharko's try it as important as it is for this, and as much as they're probably going to test you on it, it's only present in about 50, maybe 60% of patients are going to have all three. So in real life, in a clinical setting, patient may come in, they may just have jaundice and a fever. They may have abdominal pain.

Most patients are going to have abdominal pain, but they may not have jaundice, and maybe they'll have a fever as well. but only around 50 to 60% have all three. But it is important for you to know. So Sharkos triad fever, abdominal pain jaundice. Now, Reynolds Pentad adds two more onto there. And these are going to be your sicker patients or your more sick patients. And then with Reynolds Pentad, you add on hypotension and altered mental status. So hypotension altered mental status is going to be Reynolds Pentad.

And one important thing to note is that hypotension in patient. in elderly patients and patients on glucocorticoids may be the only presenting symptom for acute colangitis in elderly and patients on glucocorticoids. So let's go over that again. Charcos triad fever, abdominal pain jaundice, Reynolds, pentat, you add on hypotension and altered mental status. Those are the five that you need to know. As far as diagnosing, what do you think is going to be your first line? I'll give you a second and think about it. Ultrasound, just like all other biliary disorders. And then you can also get some labs. These patients have an infection, so they may have leukocytosis. Normally, there's going to be a neutrophil dominance in this.

And then again, you're going to see your colistatic pattern with your liver enzymes. Remember that coli static pattern is going to be your increased alkaline phosphatase, your increased GGT. Asht and ALT may be elevated as well. And then you also may see an increased bilirubin. So that's your coli-static pattern that you're going to see in these patients with this stagnant bile. So remember that alkaline phosphatase increased GGT, AST, A-L-T, Billy Rubin, all may be elevated. And remember that colistasis is going to be that reduced flow of bile, which leads to that coli-static pattern. Another way you can diagnose as well, it's a little bit more accurate than an ultrasound, but it's time-consuming, it's expensive, is an MRCP. So that's going to be an MRI

where you can visualize the gallbladder, the billiary tree and things like that. So you can do MRCP, but again, it's going to be a little bit more expensive, a little bit more time consuming your patient, maybe claustrophobic. So not as easy to do as a bedside ultrasound, but it's another option as well. As far as treatment, so the goal here is you want to get that stone out, you want to decompress the common bile duct, remove all that sludge, the bile, but before you do that, and ultimately you want to do a coliseosectomy at some point to get the gallbladder out. But before you do that, remember, these patients are really sick. So the eventual goal is to get out the stone, But first you need to stabilize these patients.

So how do you stabilize them? Well, they have an infection. So you want to give them IV antibiotics. That's what you want to start with to get these patients stable. You want to get them to a point where they're afebrile. And you just want to get them feeling better before you put them into surgery. So your IV antibiotics, again, you're going to use some broad spectrum ones. You need to make sure you're covering anorobes, your coliform bacteria, and your enteric streptococke is another common species.

So you give them IV antibiotics, these broad species. These broad spectrums, piprosilentazolectazobactin, which is zosen, septriaxone, again, with metronidazole. Those are some, it can be some of your more common antibiotics you'll use for this. So you treat them for a little while with IV antibiotics, give them some IV fluids, get them feeling better. Now they're a febrile for about 48 hours. They're stable. They're feeling better. Now you can go ahead and you can do an ERCP.

So you can get the stone out. You're going to decompress that common bile duct, which is going to be removing all of that stagnant bile, all of that sludge out of there that caused the infection in the first place. So once they're stable, about 48 hours, you go ahead and do your ERCP, pull the stone out, pull out all of that stagnant bile. And then eventually, ultimately, the patient should have an elective colisosectomy at some time in the future to prevent recurrence. But that doesn't necessarily have to be done. It could be done like a month or two later. Another option, if an ERCP is contraindicated, there's something else called a percutaneous trans hepatic colangogram, which is another way to remove

some of that sludge and all that bile and things like that if you can't do an ERCP. So acute colangitis, you're going to stabilize the patient IV antibiotics, your broad spectrum, Pptazzo, which is zosin, Cephtrioxinometrinitazole, get them a february, about 48 hours, stable, do your ERCP, get the stone out, and then at some point an elective colisestectomy to prevent recurrence. and that is biliary disorders so i hope that was helpful i try to get everything done pretty quickly there and as always thank you guys good luck on your pants your panery your iur's and good luck in pa school