Gallbladder Stone Diseases

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🌱 來自: Huppert’s Notes

Gallbladder Stone Diseases🚧 施工中

Gallbladder Stone Diseases

Cholelithiasis

•   Etiology: Stone in the gallbladder

•   Clinical features: Patients may be asymptomatic or develop biliary colic

•   Diagnosis: RUQ ultrasound

•   Treatment: Elective cholecystectomy, if symptomatic

•   Types of stones: Cholesterol: Obesity, multiparity, OCPs, rapid weight loss. Pigmented: Hemolysis, cirrhosis, biliary infections, TPN

FIGURE 4.6: Anatomy of the biliary tree and the types of gallbladder stone disease. Shown is the biliary tree and the passage of gallstones through this system: 1) Cholelithiasis; 2) Cholecystitis; 3) Choledocholithiasis; 4) Cholangitis. Of note, cholangitis can be due to obstruction from a gallstone or another cause (see chapter text).

Cholecystitis

•   Etiology: Stone in the cystic duct

•   Clinical features: Acute inflammation of the gallbladder wall which causes RUQ pain, N/V, fever, leukocytosis, +Murphy’s sign (inspiratory arrest during deep palpation of RUQ)

•   Diagnosis: RUQ ultrasound, if inconclusive consider HIDA scan

•   Treatment: IVF, NPO, IV antibiotics. Then early cholecystectomy (within 24–48 hr). If poor surgical candidate, achieve drainage with a percutaneous cholecystostomy.

•   Subtypes:

-   Acalculous cholecystitis: Cholecystitis in the absence of a stone. More common in patients that are very ill (e.g., ICU patients, burn patients). Treatment: If necrosis, perforation, or emphysematous cholecystitis, needs emergent cholecystectomy or percutaneous drainage.

-   Emphysematous cholecystitis: Infection of the gallbladder with gas-forming bacteria. Ultrasound shows air-fluid levels and gas shadows. Treatment: IVF, antibiotics, early cholecystectomy

•   Post-cholecystectomy syndrome: Persistent abdominal pain post-operatively or months/years later due to a retained stone or extrabiliary problem. Patients also may have bile salt wasting and diarrhea. Diagnosis: RUQ ultrasound, MRCP, or ECRP. Treatment: Bile acid sequestrants.

Choledocholithiasis

•   Etiology: Stone in the common bile duct

•   Clinical features: Abdominal pain, fever. Labs notable for initial transaminitis followed by a cholestatic elevation. RUQ ultrasound may show biliary dilatation.

•   Treatment: High risk: ERCP with removal of stone, followed by elective cholecystectomy. Intermediate risk: MRCP, if positive proceed to ERCP. Low risk: If gallstones/sludge seen on RUQ ultrasound, consider elective cholecystectomy.

Cholangitis

•   Etiology: Infection of the biliary ducts due to obstruction (stone, tumor, stricture), biliary stasis, or bacterial overgrowth.

•   Classic symptoms: Charcot’s triad: 1) RUQ pain, 2) Jaundice, 3) Fever. Reynold’s pentad: The prior triad and in addition: 4) Septic shock, 5) Altered mental status

•   Diagnosis: RUQ ultrasound, hyperbilirubinemia, leukocytosis, mild elevation serum transaminases

•   Treatment: IV antibiotics, IVF. Perform ERCP with sphincterotomy, stone extraction, and/or stenting within 24–48 hours