General Surgery [GALLBLADDER DISEASE]
Surgery content for this topic is a reduced and simplified version
of Internal Medicine GI-Gallbladder. It’s present for Surgery-
Only review (Shelf Studying).
Gallbladder Means Gallstones
Except for the obstructive jaundice section, gallbladder
pathology generally means gallstones. We’re going to talk about
when stones (cholelithiasis) go bad.
Normal Anatomy of the Asx Gallstones present,
Gallstones Hepatobiliary system without obstruction
Gallstones occur in females who are fat, forty, and fertile (they
have four or five kids), and fNative American (the F is silent).
and those who have a hemolytic anemia. Generally,
asymptomatic gallstones are left alone. Symptomatic
gallstones present with a colicky RUQ abdominal pain that
may radiate to the right shoulder and occur after a big fatty
meal. Symptoms are typically self-limited. An ultrasound Neg Dz Pos Dz
diagnoses it. An elective cholecystectomy can be done if the
patient desires. These will convert to Cholecystitis at 2%/yr.
Acute Cholecystitis. Gallstone HIDA scan. Normal on left has
Acute Cholecystitis lodges in Cystic Duct, inducing tracer throughout biliary system.
When a gallstone gets in the cystic duct and stays there an Inflammation of the Gallbladder. Obstruction on right prevents filling
inflammatory process develops. This causes a constant RUQ No hepatic/pancreatic of the gallbladder. Positive study.
abdominal pain accompanied by a mild fever and mild involvement involvement
leukocytosis. It’s often preceded by an episode of cholecystic
colic. There should be a Murphy's sign. Diagnose with an
ultrasound to see pericholecystic fluid, a thickened gallbladder
wall, and gall stones. Equivocal cases can be confirmed with a
HIDA scan. Urgent cholecystectomy should be performed while
still in the hospital. Perc drainage is an option.
Ascending Cholangitis and Choledocholithiasis Choledocholithiasis. Gallstones Pancreatitis.
If there’s an obstructive jaundice and/or pancreatitis along Obstruction of common duct Obstruction of common duct distal
with cholecystitis symptoms, there may be a stone in the proximal to pancreatic duct. to pancreatic duct. Biliary, Liver,
Elevation in Biliary and Liver AND Pancreatic enzymes.
common duct (choledocholithiasis). MRCP makes the
enzymes only.
diagnosis, and ERCP retrieves the stone. Eventually the
gallbladder needs to come out. Do MRCP first to avoid
iatrogenic pancreatitis with ERCP. Abx are usually given in case Ascending Cholangitis
of developing cholangitis. Choledocholithiasis + Infxn Proximal to
obstruction. Chills, High Fever, Severe
Leukocytosis
If, however, there’s a high fever (> 104.1), severe leukocytosis,
and symptoms of obstructive jaundice without peritoneal Cholangitis:
findings there’s an infection behind the stone: cholangitis. SKIP 1) RUQ Pain
the MRCP and start with ERCP (percutaneous drainage is also 2) Fever Charcot’s Triad
possible, so long as it gets decompressed) Add IV antibiotics to 3) Jaundice
cover gram negative and anaerobes (cipro + metronidazole). The 4) Hypotension
5) AMS Reynold’s Pentad
right answer when considering ascending cholangitis is to start
antibiotics and do emergent ERCP. Once stable, a
cholecystectomy is performed.
Dz Path Pt Dx Tx
Stones Cholesterol = the “Fs” ASX U/S, Diagnosis not required None
(“Lithiasis”) Pigmented = Hemolysis
Cholecystitis Cystic Duct Obstruction RUQ Pain, Murphy’s Sign U/S à HIDA Cholecystectomy
mild fever , mild leukocytosis (urgent)
Choledocholithiasis Common Bile Duct Obstruction RUQ Pain, Murphy’s Sign + U/S à MRCP ERCP (urgent),
(koh-lee-doh-koh) = Hepatitis and/or Pancreatitis ↑AST/↑ALT, ↑Lipase/↑Amylase mild fever, mild leukocytosis Cholecystectomy
also (elective)
Ascending All of the above PLUS RUQ Pain, Murphy’s Sign + U/S à MRCPàà ERCP ERCP (emergent)
Cholangitis Infection behind the stone ↑Labs, T >104, Leukocytosis severe fever and leukocytosis Cholecystectomy
(urgent)
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