Biliary Tract Emergencies

Original lecture by Dr. Peter Gruber
Conference 1/27/2016
Post by Fernando Barajas Jacobi/Montefiore EM PGY-2

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Cholelithiasis causes a spectrum of disease

The location of impaction along with the diseases associated with that are listed below.  Each one has unique physical findings, laboratory findings, and imaging

(1)Gallbladder and cystic duct⟺biliary colic and acute cholecystitis

(2)Common bile duct, Common hepatic ducts ⟺ choledocholithiasis, cholangitis

(3)Sphincter of Oddi (or ampule of vater) ⟺gallstone pancreatitis

(4)Intrahepatic ducts ⟺ right, left, segmental hepatic ducts

(5)GI tract ⟺gallstone ileus

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GALLBLADDER DISEASE

Historical clues and physical findings

1. Traditionally (biliary) colic and acute cholecystitis (AC) were considered separate entities, however they are a spectrum of diseases***
   1. Pain often, but not always in the RUQ but can be epigastric
   2. Asymptomatic cholelithiasis/biliary colic (pain <5 hours)
2. Colic—pain lasting less than 5 hours.
   1. May or may not be intermittent (vs constant)
   2. Postprandial pain intensification
3. Moral of the story is not to rely on physical or lab findings for the diagnosis
   1. Always consider it in the Elderly; always consider it if the gallbladder is present

Epidemiology

1. Yes: “fat females that are 40”
2. Associated with HIV, gastric bypass (usually have ppx cholecystectomy), rapid weight loss
3. Prevalence increases with age

Diagnosis: Imaging is a must

1. US
   1. Gallstones with thickened wall or murphy’s= 98% PPV for AC
   2. GS w/o other findings = 99% NPV for AC
2. HIDA
   1. Limited ability to delineate non-obstructive disease
3. CT
   1. Is a must if you are considering complications of AC (gangrene, emphysematous AC)
   2. Often performed if US is NOT available

 

Treatment

1. NSAIDS
   1. Pain control
   2. may decrease risk of progression of colic to AC
2. ABx recommended though AC not necessarily associated with infection
   1. There may be an increase risk of surgical site infection if antibiotics are given
3. Acalculous AC
   1. 10-15% of AC, but primarily occurs in ICU
   2. Risk factors include prolonged feeding
   3. Along with emphysematous AC, these patient most likely to require cholecystectomy due to increased risk of perforation

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ASCENDING CHOLANGITIS

Diagnosis

1. Charcot’s triad (present in 50-70%)
2. Often in the setting of choledocholithiasis
3. If your patient has undifferentiated sepsis or altered mental status
   1. ↑ T. Bili +/- ↑ amylase, transaminases, alk phos

Imaging: Opposite of AC work up

1. CT is 1st line because US has a sensitivity of 50% for choledocholithiasis
2. ERCP is gold standard
   1. It allows for disempaction, BUT
   2. Has high complication rate, so it is often deferred

Treatment

1. IVF, IVF, IVF
2. Antibiotics
3. Pressors as indicated

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PANCREATITIS

Diagnosis

1. Often requires 2 of 3: Abd pain, lipase >3x normal range, imaging
2. Lipase elevation does not correlate with severity of disease
3. Imaging:
   1. Perform a CT if there is worsening in clinical status, organ failure, or the diagnosis is unclear
   2. Defer 12-48hours as it is more helpful then

Treatment

1. IVF
   1. Amount needed is controversial
   2. The goal is to decrease BUN & HCT to decrease risk of pancreatic necrosis
2. If gallstone pancreatitis → perform ERCP

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BILIARY TRIVIA

• Causes of Jaundice:

• Diagnosing Hepatitis B:

• General Liver Function Test factoids:

• If isolated derangement → extrahepatic
• If multiple derangements → liver disease
• GGT is the only lab that is specific for liver pathology
• With chronic injury
  • LFTs are not sensitive and may even return to baseline
  • If there was hepatic necrosis → ↑PT
  • After resolution of disease → normalization of LFTs
• Transaminases
  • AST/ALT >1
    • Think alcoholic hepatitis
    • AST, however, typical <500
  •  AST/ALT<1
    • Think viral and toxic injuries
  • Alk Phos
    • If elevation >1000, consider metastatic CA

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REFERENCES

Gruber PJ, et. al. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med. 1996 Sep;28(3):273-7.

Gruber P. “Biliary Tract Emergencies” Jacobi Medical Center. Jacobi/Montefiore Emergency Medicine Conference. Bronx. Jan 2016. Lecture