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Disorders of the Gallbladder and Biliary Tract (GALLBLADDER DISORDERS…

- - - - cholesterol gallstone: three main Fs for formation:
        Fs influencing nucleation: bile transit time, gallbladder contraction, bile composition (concentrations of cholesterol, phospholipids, and bile salts), and presence of bacteria, mucin, and glycoproteins,
        
        cholesterol saturation: incr by estrogens, multiparity, OCP, obesity, rapid weight loss, and terminal ileal disease, which decr bile acid pool.
        
        Nucleation: enhanced by biliary parasites, recurrent bacterial infection of biliary tract, and antibiotics such as ceftriaxone (concentrates and crystallizes w/ Ca), Total parenteral nutrition and blood transfusions also promote bile pigment accumulation and gelfaction of sludge.
        
        Bile stasis: caused by gallbladder hypomotility (resulting from pregnancy, somatostatin, or fasting), bile duct strictures, choledochal cysts, biliary parasites, and total parenteral nutrition
      - pigment stone formation: incr production of bilirubin conjugates (hemolytic states), incr biliary Ca2+ HCO3 −, cirrhosis, and bacterial deconjugation of bilirubin to a less soluble form
    - - 50-60%: asymptomatic; Prophylactic cholecystectomy:
        (1) diabetes (greater morbidity/mortality from acute cholecystitis)
        (2) a calcified (porcelain) gallbladder, large gallbladder polyps, or large stones (>3 cm), (a. w/ incr risk for gallbladder carcinoma)
        (3) sickle cell anemia, (in whom hepatic crises difficult to differentiate from acute cholecystitis)
        (4) children (frequently develop symptomatic disease)
        (5) Native Americans, (predisposed to gallbladder cancer)
      - one third: biliary colic or chronic cholecystitis
        
        Biliary colic: when gallbladder contracts against outlet obstruction; starts as a steady ache; sudden onset, reaches plateau over a few minutes, subsides gradually over 30 mins to several hrs; Referred pain at tip of scapula or right shoulder; Nausea and vomiting may occur, but fever and a palpable mass (signs of acute cholecystitis) are not evident
        
        Gallstones best demonstrated by transabdominal ultrasonography (initial test to evaluate cholelithiasis): sensitivity and specificity >90%, but accuracy drops to 20% for visualization of stones within common bile duct--> endoscopic ultrasonography (EUS) + MRCP (90% to 95% for detecting cholelithiasis and common bile duct stones)
        
        gallbladder removal indicated--> laparoscopic cholecystectomy choice for recurrent biliary pain; open cholecystectomy reserved for high-risk (e.g., prior abdominal surgery w/ adhesions, obesity, cirrhosis)
        Factors that may predict choledocholithiasis: jaundice, pancreatitis, abnormal liver test results, and bile duct dilation
      - 15%: acute complications
        
        clinical hallmark: acute onset of upper abdominal pain lasting for several hours; gradually incr in severity and typically localizes to epigastrium or right hypochondrium w/ radiation to R lumbar, scapular, and shoulder area. Nausea and vomiting, anorexia, and low-grade fever common; pain DOES NOT subside spontaneously;
        P/E: inspiratory arrest on palpation of RUQ (Murphy’s sign), fever, and, less commonly, mild jaundice or a palpable gallbladder.
        
        Complications: emphysematous cholecystitis (in diabetes, older adults, and immunosuppressed)
        Mirizzi syndrome: profound jaundice resulting from extrinsic compression of bile duct by an impacted stone in cystic duct at gallbladder neck
        
        transabdominal ultrasound study w/ strong supportive evidence:
        gallstones, along w/ pericholecystic fluid, gallbladder wall thickening, and localized tenderness over gallbladder (ultrasonographic Murphy’s sign)
        Radionuclide scanning: if contrast material enters bile duct and duodenum w/o gallbladder visualization, acute cholecystitis strongly supported.
        
        high risk for recurrent acute cholecystitis--> most need cholecystectomy (often performed within first 24 to 48 hours after presentation or, less often, 4 to 8 weeks after an acute episode)
        CholecystOSTomy: pxs who have a high operative risk. Antibiotics typically used when fever or leukocytosis is present.
        Expectant management reserved for uncomplicated disease who are not good operative candidates and those in whom the diagnosis is not clear
- - - - Gallstone Pancreatitis
        recurs in 25%--> cholecystectomy once recovered clinically from an attack of pancreatitis. If px remains jaundiced during an attack, suggesting presence of a stone in bile duct, an ERCP with sphincterotomy is performed to extract the stone.
      - Acute Cholangitis (suppurative)
        a life-threatening infection of biliary tract (a medical-surgical emergency that can lead rapidly to sepsis, shock, and death)
        classic: abdominal pain, jaundice, and fever (Charcot’s triad). (may be absent or atypical in elderly or immunosuppressed)
        Dx based on a compatible clinical and laboratory picture (abnormal liver function test results and leukocytosis) together w/ radiologic or endoscopic evidence of common bile duct stones.