Gallstones And Biliary Tract Disease! Trivia Quiz

Key Concept/Objective: To understand the different imaging modalities for diagnosing cholecystitis
Transabdominal ultrasonography is the diagnostic procedure of choice for a patient with suspected gallstones and acute cholecystitis. A meta-analysis revealed that ultrasonography has a sensitivity of 88% to 90% and a specificity of 97% to 98% for the diagnosis of gallstones greater than 2 mm in size. Gallbladder ultrasonography should ideally be preceded by an 8-hour fast, because gallstones are best visualized in a distended, bile-filled gallbladder. Cholescintigraphy is the best method of confirming the clinical diagnosis of acute cholecystitis. This procedure, which takes only 60 to 90 minutes, involves the intravenous injection of technetium-99m-labeled hepatoiminodiacetic acid (HIDA, or lidofenin), which is selectively excreted into the biliary tree and enters the gallbladder. In the presence of acute cholecystitis, radiolabeled material enters the common bile duct and duodenum but not the gallbladder. A meta-analysis suggested that radionuclide scanning is the most accurate method of diagnosing acute cholecystitis. Occasionally, the scan gives false positive results in patients who have alcoholic liver disease, in those who are fasting, or in those receiving total parenteral nutrition; however, false negative results are rare. Radionuclide scanning may not be useful for patients with deep jaundice, because the labeled agent fails to enter the biliary tree.

Key Concept/Objective: To know which bacteria are associated with emphysematous cholecystitis
Emphysematous cholecystitis, which is associated with a higher morbidity than uncomplicated acute cholecystitis, is usually caused by gas-forming bacteria, such as C. perfringens and other clostridia, Escherichia coli, or anaerobic streptococci. Patients who have such infections are often very ill, and 20% also have diabetes or are compromised by coexisting conditions. Emphysematous cholecystitis occurs three times more often in men than in women. Many cases of this type of cholecystitis are not associated with cholelithiasis. A plain abdominal x-ray, ultrasound, or CT scan frequently reveals gas within the gallbladder.

Key Concept/Objective: To understand the role of dissolution therapy in patients who are poor surgical candidates Oral bile acids such as ursodeoxycholic acid (8 to 12 mg/kg/day) and chenodeoxycholic acid (13 to 15 mg/kg/day) can decrease biliary cholesterol levels with complete gallstone dissolution; when administered for months to years, ursodeoxycholic acid and chenodeoxycholic acid can result in complete gallstone dissolution in 30% and 14% of patients, respectively. In one study, combination therapy with these two agents was not found to be superior to monotherapy with ursodeoxycholic acid. Chenodeoxycholic acid has largely been replaced by the safer ursodeoxycholic acid. However, these drugs are effective only in patients who have small cholesterol stones and a functioning gallbladder. A high rate of gallstone recurrence is noted after cessation of therapy. The infusion of methyl tert-butyl ether through a transhepatic catheter directly into the gallbladder can rapidly dissolve cholesterol stones. The rapid infusion and removal of this ether, which remains liquid at body temperature, results in the dissolution of most cholesterol gallstones within 4 to 31 hours. Dissolution therapy has limited value except in patients who are poor candidates for surgery.

Key Concept/Objective: To know that endoscopic retrograde cholangiopancreatography is both a diagnostic and therapeutic modality ERCP allows radiographic visualization of the biliary tree and the option of therapeutic intervention. EUS has greater sensitivity and specificity than ERCP in the detection of common bile duct stones but lacks the therapeutic option available with ERCP. Therefore, ERCP is the test of choice if common bile stones are highly suspected on the basis of history, physical examination, and laboratory and imaging studies. Percutaneous transhepatic cholangiography (PTC) involves accessing the bile ducts via a small needle. The success rate of PTC in patients with dilated ducts is close to 100%; nondilated ducts are entered successfully about 70% of the time. Complication rates for both ERCP and PTC approach 5%. ERCP has replaced PTC as the technique of choice.

Key Concept/Objective: To reinforce that HIDA cholescintigraphy is the test of choice for confi rmation of a clinical diagnosis of acute cholecystitis
TUS is the diagnostic procedure of choice for a patientwith suspected gallstones and acute cholecystitis. Ameta-analysis revealed that ultrasonography had asensitivity of 88 to 90% and a specifi city of 97 to 98% forthe diagnosis of gallstones greater than 2 mm in size.Gallbladder ultrasonography should ideally be preceded byan 8-hour fast because gallstones are best visualized in adistended, bile-fi lled gallbladder. In addition to detectinggallstones, ultrasonography can be used to identify othercauses of right upper quadrant pain, such as hepatic abscessor malignancy, and it may reveal biliary duct obstruction.However, specifi c evidence of acute cholecystitis (i.e., thepresence of pericholecystic fl uid, edema of the gallbladderwall, or both) is found infrequently. Occasionally, aso-called sonographic Murphy sign is elicited when theultrasound probe is positioned below the right costalmargin. Cholescintigraphy is the best method of confi rmingthe clinical diagnosis of acute cholecystitis. This procedure,which takes only 60 to 90 minutes, involves the intravenousinjection of technetium-99m-labeled HIDA (lidofenin),which is selectively excreted into the biliary tree and entersthe gallbladder. In the presence of acute cholecystitis,radiolabeled material enters the common bile duct andduodenum but not the gallbladder. A meta-analysissuggests that radionuclide scanning is the most accuratemethod of diagnosing acute cholecystitis. Occasionally, thescan gives false positive results in patients who havealcoholic liver disease, in those who are fasting, or in thosereceiving total parenteral nutrition; however, false negativeresults are rare. Radionuclide scanning may not be usefulfor patients with deep jaundice, because the labeled agentfails to enter the biliary tree.

Key Concept/Objective: To recall that in unstable patients with cholangitis, placement of a cholecystotomy tube improves mortality In patients with acute cholecystitis, laparoscopic cholecystectomy should be performed within 96 hours of the onset of symptoms because the increasing infl ammatory changes that occur over time have been implicated in bile duct injury; these changes may necessitate converting the procedure to an open cholecystectomy. Some patients (e.g., those with septic shock, peritonitis, severe pancreatitis, portal hypertension, or marked clotting disorders) are not candidates for laparoscopic cholecystectomy. These patients should generally undergo either open cholecystectomy, if their condition permits, or simple cholecystostomy. Cholecystostomy, either operative or percutaneous and performed under ultrasound guidance, involves extracting the stones and draining the biliary tree through a catheter left in the gallbladder. Percutaneous cholecystostomy is superior to gallbladder aspiration in severe acute cholecystitis. Cholangiography can be carried out later through this drainage catheter. For patients who respond to cholecystostomy and who improve enough to become candidates for elective surgery, interval November 2008 â?? 8 cholecystectomy is recommended because the risk of recurrent symptoms is signifi cant. Endoscopic interventions in experienced hands may have a role in treating acute cholecystitis. Endoscopic ultrasound-guided transmural cholecystostomy and ERCP with sphincterotomy has been used in small groups of elderly or high-risk patients with acute cholecystitis.

Key Concept/Objective: To recall that cholecystectomy is the treatment of choice for chronic cholecystitis Elective cholecystectomy is indicated for patients who have symptomatic gallstones and chronic cholecystitis. Recurrent pain is to be expected in these patients if cholecystectomy is not performed. As many as 50% of patients with symptomatic gallstones who do not undergo cholecystectomy experience serious complications within 20 years of the initial onset of symptoms. It is occasionally diffi cult to determine whether abdominal symptoms are secondary to documented gallbladder disease. A history of typical recurrent pain makes this determination easier. In certain cases, elective cholecystectomy is performed as a last diagnostic procedure when a thorough search for other causes of abdominal symptoms has proved negative. All too often, the symptoms recur postoperatively.

Key Concept/Objective: To reinforce that conservative therapy without surgery is recommended for diabetic patients with asymptomatic cholelithiasis Patients who have asymptomatic gallstones should generally be managed conservatively without surgery. Exceptions may be made for patients at increased risk for gallbladder cancer, such as Pima Indians, persons with calcifi ed gallbladders (porcelain gallbladder), patients with very large gallstones (> 3 cm), and patients with an associated gallbladder polyp greater than 10 mm in diameter. In the past, prophylactic cholecystectomy was recommended for diabetic patients who had asymptomatic gallstones; anecdotal reports suggested that such patients did poorly when cholecystectomy was performed as an emergency procedure. However, two well-controlled retrospective studies of patients undergoing surgery for acute cholecystitis, as well as a decision analysis, showed that diabetes was not an independent risk factor for operative mortality or serious postoperative complications, and prophylactic cholecystectomy resulted in a shortened life span. Thus, prophylactic cholecystectomy cannot be recommended for patients with diabetes.

Key Concept/Objective: To review that the gold standard for diagnosis of SOD is ERCP with manometry SOD is a benign condition of intermittent or permanent obstruction of biliary drainage, pancreatic drainage, or both that is caused by either a stenosis or smooth muscle dysfunction of the sphincter muscle. Biliary SOD is usually seen in women in their fourth to sixth decades of life. The symptoms arise typically after cholecystectomy, although SOD may occur in patients with an intact gallbladder. The clinical presentation of biliary SOD is episodic abdominal pain in the epigastric or right upper quadrant region that may radiate to the back or shoulders. It may be associated with nausea or vomiting that worsens with eating. Laboratory tests may reveal abnormalities in liver function. Right upper quadrant sonography and CT may reveal a dilated common bile duct. ERCP with SOD manometry is the gold standard for the diagnosis of SOD. A basal sphincter pressure of greater than 40 mm Hg is abnormal and indicative of SOD. Other tests that are noninvasive and less reliable may also indicate the presence of SOD; such tests include a provocation test using morphine (or neostigmine), which produces biliary pain and serum aminotransferase elevation; ultrasound evaluation of dilation and emptying of the common bile duct after secretin stimulation; and the scintigraphic evaluation of the kinetics of ductal emptying. Secretin-stimulated MRCP with manometry may be useful in selecting patients who would most benefit from endoscopic therapy.