ERLINA MARFIANTI, MSC,SPPDBLOK NUTRISI DAN DIGESTIVA, 25 APRIL 2011

CHOLELITHIASIS&CHOLECYSTITIS

OBJECTIVEUnderstand and Identify the anatomy of the biliary systemDescribe the epidemiology of Biliary diseasesDiscuss the lab test and imaging studies used to evaluate biliary diseasesCompare and contrast biliary colic, chronic cholecystitis, acute (acalculous vs calculous) cholecystitis, choledocholithiasis, obstructive jaundiceDescribe management of acute Cholesistitis

ANATOMYCalots Triangle: inferior margin of the liver superiorly, CHD medially, cystic duct laterallyGallbladder: Fundus, body, neck, cystic duct, infundibulumSphincter of Oddi, Ampulla of VaterPancreatic ducts- Wirshung and Santorini

CHOLELITHIASIS (GALL STONE)

Spectrum of Gallstone DiseaseSymptomatic cholelithiasis can be a herald to:an attack of acute cholecystitisor ongoing chronic cholecystitisMay also resolve

EpidemiologyAlthough 10% to 15% of people in the United States develop gallstones, fewer than half of those with gallstones have symptoms, and fewer than 10% develop potentially life-threatening complicationsCholesterol gallstones are less common in black people

Risk Factor4 Fs: FEMALE, FAT, FERTILE, FORTY

Other risk factors: Estrogen preparat use, rapid weight loss, family history, chronic hemolysis, SB resection, Total Parental Nutrition , Crohns disease (terminal ileum)DM, Insulin Resistance, Drugs: Clofibrate, octreotide, ceftriaxonProlonged fasting microlithiasis

GallstonesUncommon in children (seen with hemolytic, idiopathic, cystic fibrosis, obesity, ileal resection, long term use of TPN)Elderly 14-27% symptomatic gallstone diseaseMore likely biliary sepsis/gangrenous GB perioperative morbidityMortality rate 19%

Gallstone Risk FactorsFamilialAsian descentChronic biliary tract infectionsParasitic infections (ascaris lumbricoides)Chronic liver diseaseChronic intravasular disease (Sickle Cell, Hereditary Scherocytosis)Hepatitis A, B, C, EHIVHerpesvirus

Bile is made up of what?Cholesterol, bile acids, phospholipids (lecithin), conjugated bilirubin, proteinPredominantly chemical compisition gallstone: cholesterol or calcium bilirubinate stonesGallbladder sluge assoc prolonged TPN, starvation, rapid weight loss. Precursor to gallstones

Clinically PresentationBilary colic = cystic duct blockage from impacted stonesHistory/PEPostprandial abdominal pain RUQ radiating to scapula, epigastric painThe pain may last from several minutes to several hours.Abrupt onset, and gradual relief, nausea, vomiting.Usually fatty food intolerance, dyspepsia, flatulence

Jaundice

Biliary ColicThe pain of biliary colic is from contraction of the gallbladder, which cannot empty because the cystic duct is obstructed by a stone.The gallbladder is stimulated to contract primarily by cholecystokinin, which is released from the small bowel mucosa. The pain resolves after the gallbladder stops contracting or when the cystic duct becomes patent again.

Cinically PresentationAcute cholecystitis

is the initial presentation of symptomatic gallstones in 15% to 20% of patients.Patients with acute cholecystitis experience severe pain that persists for several hours, until they finally seek help at a local emergency room.Whereas in biliary colic the cystic duct obstruction is transient, in acute cholecystitis it is persistent. Persistent cystic duct obstruction, in combination with chemical irritants in the bile, results in inflammation and edema of the gallbladder wall. Nausea and vomiting are common.

Clinically Examinationmild epigastric or right upper quadrant tenderness,but most patients do not have significant physical findings.Acute Cholecystitismarked tenderness in the right upper quadrant, often associated with a definite mass or fullness. Palpation of the right upper quadrant during inspiration often causes such severe discomfort that the patient stops inspiring (a positive Murphy sign). Local peritoneal signsand fever are common.

DiagnosisDiagnosis: Abdominal ultrasound: gallstones (85-90%)scan: r/o cystic duct obstruction, CBD obstructionCholescintigraphy 95% accurate in the outpatient diagnosis of acute cholecystitisLFTs: ALT, AST, ALK PHOS, TB, DBAmylase, LipaseCBC

About 10% of stones are radiopaque

Can be viewed with radiographic contrast

Sonography is now the method of choice

Composition of stones varycholesterol, bilirubin, calcium

http://www.goldbamboo.com/pictures-t1349.htmlGallstones

TreatmentTreatment:eletive cholecystectomyExtracorporeal shock wave lithotripsy (ESWL)or oral solution Ursodeoxycholic acid (only for cholesterol stones)

Complications of cholelithiasis: recurrent biliary colic pain, choledocholithiasis, pancreatitis, cholangitis

How to decrease the risk of gallstone formation?Avoid obesityHigh fiber dietLow saturated fat dietsSmall meals at regular intervals

CholedocholithiasisCan present similarly to cholelithiasis, except with the addition of jaundiceDDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with painTx: Endoscopic retrograde cholangiopancreatography (ERCP)Stone extraction and sphincterotomyInterval cholecystectomy after recovery from ERCP

Biliary Tract Emergencies Related to Gallstones1) Biliary Colic2) Cholecystitis3) Gallstone pancreatitis4) Ascending cholangitis

CholecystitisPathophysiologyInflammation of the GallbladderCholelithiasisChronic CholecystitisBacterial infectionAcalculus CholecystitisBurns, sepsis, diabetesMultiple organ failure

CholecystitisSigns & SymptomsURQ Abdominal PainMurphys signSteady, severe pain, and tendernessNausea, VomitingFever and leucocytosisJaundive Mirrizys syndromeHistory of Cholecystitis

Risk Factors for Acute CholecystitisAssociated with gall stone Critical ill patientsCaused By Infectious agents

Pathogens Involved in AcuteCholecystitisE. coli/Klebsiella-70%Enterococci-15%Bacteroides-10%Clostridium-10%Group D StrepStaphylococcal species

Clinical FeaturesOverlap of UD, gastritis, GERD, nonspecific dyspepsiaRUQ painUpper abd/epigastric painRadiation to L upper backPain persisant lasting 2-6h

Differential DiagnosisGastritisGERDPancreatisHepatitisPUDAMI in elderlyAcute renal colicAcute pyeloAppendicitis (pregnancy, retrocecal)PIDFitzhugh-Curtis Syn.EctopicPneumoniaPleural Effusion

Clinical Features of Acute CholecystitisPainNausea,VomitusAnorexiaFever, chills+Murphys sign ( pain or inspiratory arrest with deep, subcostal palpation on inspiration

Acute calculous cholecystitisPersistent cystic duct obstruction leads to Gall B ladder distension, wall inflammation & edemaCan lead to: empyema, gangrene, rupturePain usu. persists >24hrs & Nausea &Vomitus&FeverPalpable/tender or even visible RUQ massNuclear HIDA scan shows nonfilling of GB

Acalculous Cholecystitis5-10% incidenceElderlyDMMultiple traumaExtensive burnsProlonged LaborMajor surgeryGB torsionSystemic vasculitis statesBacterial or parasitic infection of biliary tract

Acute acalculous cholecystitisIn 5-10% of cases of acute cholecystitisSeen in critically ill or prolonged TPNMore likely to progress to gangrene, empyema, perforation due to ischemiaCaused by gallbladder stasis from lack of enteral stimulation by cholecystokininTx: NPO, IVF, AntibiotikaCholecystectomyTreat of underlying disease

Complications of acute cholecystitis

Empyema of gallbladderPus-filled GB(Gall Bladder) due to bacterial proliferation in obstructed GB. Usu. more toxic, high feverEmphysematous cholecystitisMore commonly in men and diabetics. Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumenPerforated gallbladderOccurs in 10% of acute cholesistitis, usually becomes a contained abscess in RUQLess commonly, perforates into adjacent viscus = cholecystoenteric fistula & the stone can cause SBO (gallstone ileus)

Chronic calculous cholecystitisRecurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstonesOvertime, leads to scarring/wall thickening

Diagnostic StudiesMost important is high clinical suspicion and U/S.Usually labs (CBC, bilirubin, Alk. Phos, LFTs, Lipase)CXR-12 Lead EKG- r/o ACSUSGCT when ? other intraabdominal pathHIDA Scan

ComplicationsFluid & Electrolyte deficiencies- due to vomiting & anorexiaUpper GI hemorrhage- Mallory-Weiss tearsGallstone pancreatitisAscending cholangitisCholecystitisGB EmpyemaEmphysematous (gangrenous) GB

TreatmentUncomplicated Symptomatic Cholelithiasis No immediate surgery, Elective cholecystectomy, Control symptomsAntispasmodicsOpiates (Meperidine preferred)AntiemeticsKetorolac (relieves GB distention)Replace fluids & electrolytes

Tx: NPO, IVF, AntibiotikaCholecystectomy

TreatmentAcute Acalculous/Calculous CholecystitisIf septic wide spectrum abx and immediate surgeryIf not septic single agent abx (3rdgen cephalosporin), surgery within 24-72 hours

CholangitisInfection of the bile ducts due to CBD obstruction 2ndary to stones, stricturesCharcots triadMay lead to life-threatening sepsis and septic shock Tx: NPO, IVF, IV AbxEmergent decompression via ERCP or perc transhepatic cholangiogram (PTC)Used to require emergency laparotomy

All of the following are risk factors for development of gallstones except:A. PregnancyB. >50 yoaC. FemaleD. ObesityE. Asian descent

4) Clinical features of cholecystitis include all of the following except:A. RUQ abdominal painB. Radiation to R upper backC. Nausea, VomitingD. + Murphys signE. Fever

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