Biliary Disease

Biliary Disease – Alex Wiles

Pearls:

  • ERCP is not available at VA: requires fee-basis consult to VUMC, contact GI to arrange
    • Prior cholecystectomy CBD normally dilates to 10 mm, not pathologic
    • Expect some CBD dilation after stent placement, pneuomobilia often occurs as well
    • CBD dilation classically > 6mm, but CBD dilates with age: 70 yo 7mm, 80 yo 8mm; opiates can also cause biliary dilatation
    • CT has low sensitivity for stones, so get the RUQ U/S

 

Biliary Colic

  • Transient biliary obstruction typically at the GB neck without GB inflammation (no fever)
  • Presentation: Constant (not colicky) intense, dull RUQ pain and N/V for 30 minutes to 6 hours, then resolves, provoked by fatty foods (CCK), absent Murphy’s sign
    • Evaluation: Normal (CBC, LFTs, Lipase, Lactate)
  • Imaging: RUQ U/S: cholelithiasis (stones in GB)
    • Management: Elective cholecystectomy as outpatient

 

Acute Calculous Cholecystitis

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  • Inflammation of the GB (obstructing stone in the GB neck or cystic duct)
  • Ddx: PUD, pancreatitis, choledocholithiasis, ascending cholangitis, IBD, Fitz-Hugh Curtis
  • Presentation: Severe constant RUQ pain, fever/chills, N/V, + Murphy sign
  • Evaluation: CBC (leukocytosis), CMP (mild AST/ALT , nL bili), Lipase, Lactate, BCx x2
  • Imaging: RUQ U/S: gallstones + GB wall thickening or pericholecystic edema
    • If U/S non-diagnostic (no stones or GB inflammation) HIDA Scan (lack of GB filling)

 

Management: NPO, IVF, IV Abx until resolved or surgical removal

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  • Urgent Cholecystectomy (<72H) with EGS;
    • If poor surgical candidate: Cholecystostomy with IR; endoscopic drainage options for selected patients (i.e. poor surgical candidates also with ascites)
    • Complications: gangrenous cholecystitis, perforation, emphysematous cholecystitis, chole-cysto-enteric fistula, gallstone ileus

 

Acute Acalculous Cholecystitis:

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  • Inflammation of the GB without obstructing stone (due to stasis and ischemia)
  • Presentation: Seen in critically ill/ICU pts; similar history as above; may present as unexplained fever or RUQ mass (rarely jaundice)
  • Ddx: calculous cholecystitis, pancreatitis, hepatic abscess
  • Evaluation: Same as acute calculous cholecystitis
  • Imaging: GB wall thickening, pericholecystic edema, intramural gas, GB distention

 

Management: Supportive care, antibiotics, GB drainage

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  • IVF, correct electrolyte abnormalities, NPO
  • Broad spectrum antibiotic coverage
  • Place CT-guided procedure consult for cholecystostomy placement
  • Consult EGS if necrosis, perforation, or emphysematous changes present

 

 

 

Choledocholithiasis:

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  • Obstruction of biliary outflow by CBD stone without inflammation (no fever) 
    • Impacted cystic duct stone (cholecystitis) or compressing CBD (Mirizzi syndrome)
  • Presentation: RUQ pain (can be painless), N/V and jaundice
  • Evaluation: CMP and D-bili (Bili/ALP/ GGT ↑↑↑, AST/ALT mild ), CBC (Leukocytosis suggests cholangitis), Lipase
  • Imaging: RUQ U/S: dilated CBD (ULN is 6mm) MRCP/EUS vs ERCP (see below)
    • MRCP preferred given non-invasive but has lower sensitivity for smaller stones (consider EUS if still have suspicion despite negative MRCP)

 

Management

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  • NPO & IVF, pain control PRN
  • Guidelines recommend use of RUQ U/S and LFTs to help decide on MRCP vs ERCP based on likelihood of CBD stone.  You must be confident there is a CBD stone prior to ERCP given risks associated with procedure
  • High Risk: presence of any of the three following criteria consider urgent ERCP
    • CBD stone seen on imaging
    • Ascending Cholangitis
    • TBili > 4 AND CBD dilation (> 6 mm, unless prior cholecystectomy or elderly)
      • Intermediate Risk: warrants further evaluation with either MRCP or EUS prior to ERCP or cholecystectomy with intraoperative cholangiogram (obtain MRCP if overnight, discuss with GI fellow)
        • CBD Dilation; Age > 55
        • Abnormal liver enzymes (CBD stone can cause any pattern of LFT abnormalities)
      • Low Risk: for patients with symptomatic cholelithiasis and no risk factors as above; no further evaluation required, can go to cholecystectomy + IOC

 

Acute Cholangitis:

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  • Bacterial infection of biliary tract 2/2 obstruction or prior instrumentation (ERCP)
  • In ERCP-naïve pts, this is typically in setting of choledocholithiasis
  • Pts with malignant obstruction typically do not develop cholangitis
  • Presentation: Charcot triad (RUQ P, F/C, Jaundice); Reynolds’ Pentad (AMS, Hypotension)
  • Evaluation: CBC, CMP (D bili, ALP ↑↑↑) Blood Cultures, Lipase, Lactate
    • CRP, AST/ALT can be ↑↑ as well
  • Imaging: RUQ U/S: dilated CBD (ULN is 6mm), no need for MRCP/EUS
    • Consider MRCP overnight if ERCP is not being done emergently

 

Management: NPO, IVF, IV Abx; Consult GI for urgent ERCP (generally within 24 hr)

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  • If ERCP not feasible or fails to establish biliary drainage, can consider EUS-guided biliary drainage, percutaneous transhepatic cholangiography, or surgical decompression
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  • Antibiotics for Biliary Disease (IDSA Guidelines):
    • Mild to moderate acute cholecystitis (stable):
      • Ceftriaxone 2g daily, Cefazolin 1-2g q8H
    • Cholangitis or Severe acute cholecystitis (unstable or immunocompromised):
      • Covering for GNRs and Anaerobes; 3 options:
        • Zosyn 3.375g q8H, Meropenem 1g q8H or Cipro 500 q12H and Flagyl 500 q8H
        • Healthcare-associated Biliary infections: consider Vancomycin (order w/ PK consult)