1. All you ever wanted to know (or maybe didn't) about
Biliary Emergencies
Jason Branch, MD

2. Overview Background Cholic Cholecystitis Ascending cholangitis
Gallbladder empyema
Empysematous cholecystitis
Gallstone pancreatitis
Gallstone ileus

3. Bile

4. Phospholipids (lecithin)‏
Bile
Water
Cholesterol
Bile pigments
Bile salts
Phospholipids (lecithin)‏

7. Anatomy

9. Cholesterol (70%), radiolucent Pigment (20%), radiopaque
Stones
Three types:
Cholesterol (70%), radiolucent
Pigment (20%), radiopaque
Mixed (10%), radiopaque

11. Biliary Cholic

12. - symptomatic cholelithiasis
Biliary Cholic
Definition:
- not cholic
- symptomatic cholelithiasis

13. Pathophysiology: Biliary Cholic - stone obstructs cystic duct or CBD
- incr. intralumenal pressure, GB distention,
ischemia, inflamitory response
pain + systemic response

14. Biliary Colic
H&P
Classic: female, obese, fertile, 40-ish

16. Biliary Colic -female -multiparity -increased age -obesity
-rapid weight loss
-drugs
oral contraceptives
octreotide
estrogens/progesterones
ceftriaxone
clofibrate
-family history
-CF
-chronic hemolysis
-Asian, Pima Indians, Scandinavians
-fasting
-TPN
-parasites

17. Biliary Colic -N/V, RUQ pain radiating to
ipsilateral shoulder, 2-6 hours,
(2/3 after meals)‏
-Witching hour

18. Acute Cholecystitis

19. Acute Cholecystitis “Biliary colic that won't go away” (> 6 hours)‏
Same pathophysiology as biliary colic

20. Hx Acute Cholecystitis Fevers, chills, N/V, anorexia
poorly localized then sharp RUQ pain

21. PE Acute Cholecystitis may appear toxic + Murphy's sign
volume depleted
decreased BS
abdominal distention

23. Acute Cholecystitis
What constitutes a positive Murphy's sign?

29. Acute Cholecystitis Diagnostics - biliary colic – labs usually WNL
- acute cholecystitis – CBC may show white
count with left shift
- bilirubin and alk phos nl to mildly
elevated
- check lipase, urine, preg, chem 7

30. Acute Cholecystitis
But . . .
no labs or combo of labs very sensitive

31. Acute Cholecystitis
Adjuncts:
CXR r/o pneumonia
EKG in elderly

32. Acute Cholecystitis
Imaging: where the money is. US
HIDA/DISIDA CT

33. Acute Cholecystitis Ultrasound primary study of choice
Sensitivity = 94%
Specificity = 78%

34. Acute Cholecystitis Ultrasound - GB wall thickness > 5 mm
- gallstones
- CBD stones
- dilated CBD > 8 mm
- pericholecystic fluid
- other pathology

37. Acute Cholecystitis CT sensitivity = 50% for cholecystitis
may find other pathology

38. Acute Cholecystitis HIDA Most accurate indicated if US equivocal
- none in GB 1 hour post ingestion =
cystic duct obstruction

39. Acute Cholecystitis
DISIDA
use if serum bili 5 mg/dL

40. Colic & Cholecystitis Treatment and Disposition
Colic - will resolve spontaneously
Can D/C home after 4-6 with improvement
Vicodin and follow up

41. Colic & Cholecystitis Treatment and Disposition
Cholecystitis – admission, surgery consult
analgesia (meperidine ( mg/kg IV,
morphine, ketorolac)‏
antibiotics (50-80% have bacterial
pathogens present)‏

42. Colic & Cholecystitis Bugs: Enterobactereciae (E. Coli, Kleb) 70%
enterococci (15%)‏
Bacteroides (10%)‏
Clostridium species (10%)‏
Strep and Staph

43. Colic & Cholecystitis Antibiotics For nonseptic:
3rd gen cephalosporin:
cefotaxime or ceftazidime 1-2 g IV Q8-12
ceftriaxone 1-2 g IV Q12-24

44. Colic & Cholecystitis Antibiotics For septic: Triple therapy:
ampicillin 0.5-1g IV Q6
gentamycin 3 mg/kg/day IV given Q8
clindamycin mg/day divided
(or metronidazole)‏

45. Case study:
48-y.o. Female comes in with severe abdominal pain and fever. She has a history of gallstones. Her pain is in the RUQ and she also complains of chills and that her skin has been looking kind of yellow. She also says her stools have been the color of clay.
VS: T 39.2C HR 110, RR 26, BP 90/60
Exam: lethargic woman with jaundice and extreme RUQ pain

47. Ascending Cholangitis
Pathohysiology:
Stone in CBD causes infection in bile ducts, spreads to liver.
Charcot's triad:
Reynold's pentad:
Fever, RUQ pain, jaundice
Confusion and shock

49. Review Cholelithiasis Cholecystitis Cholangitis
Right upper quadrant or epigastric pain, often colicky and postprandial
Pain may radiate to shoulder or around waist
Nausea and vomiting may be present
Cholecystitis
Same manifestations as those for cholelithiasis, plus
Murphy sign present
Fever and chills may be present
Cholangitis
Same manifestations as those for cholecystitis, plus
Jaundice
Altered mental status
Shock

50. Gallbladder Empyema Results from obstruction of the cystic duct
Presents like acute cholecystitis, but can progress to sepsis (without jaundice).

52. Emphysematous Cholecystitis
~ 1% acute cholecystitis
Gas forming pathogens
Clostridium species, E. coli, Kleb

53. Emphysematous Cholecystitis
Proposed factors:
-Vascular compromise of the gallbladder
-Gallstones
-Impaired immune protection
-Infection with gas-forming organisms

54. Emphysematous Cholecystitis
Hx:
Typically 60-year old male with diabetes
PE:
Fever, tachycardia.
RUQ tenderness, possibly palpable GB
Bowel sounds are diminished or absent
* Transient relief of right upper quadrant pain followed by the appearance of peritoneal signs = hallmark of perforation.

55. Emphysematous Cholecystitis
Labs:
Very high leukocytosis
normal to slightly elevated LFTs
Images:
Gas can interfere with ultrasound
"ring-down effect" or "comet tail”
"effervescent bile"
CT if US or Abd X-ray non-diagnostic

57. Emphysematous Cholecystitis
Treatment:
-Same antibiotics as for acute cholecystitis
-Fluids, electrolyte correction
-Surgery

58. Gallstone pancreatitis
~ 40% of pancreatitis cases associated with gallstones.
Highest risk: Caucasian and Hispanic women.
Sx of biliary disease or pancreatitis (may be hard to differentiate by exam)
Increased amylase, lipase , ALT
US/CT

59. Gallstone pancreatitis
Definitive treatment is surgery
pancreatitis will usually resolve
+/- ERCP

61. A 55-year-old woman with a history of radiation enteritis and biliary colic, resulting in laparoscopic cholecystectomy 10 days prior to admission, presented to the emergency department (ED) after 7 days of progressive epigastric pain, abdominal distention, nausea, and vomiting. Physical examination revealed diffuse abdominal tenderness, which was greatest in the epigastric region and right upper quadrant, without palpable mass. Abdominal radiography showed a dilated loop of small bowel, scattered air-fluid levels, and decompressed colon (Figure 1). An emergent right upper quadrant ultrasound request from the ED was considered, but computed tomography (CT) scanning was recommended, as it would be able to assess the small-bowel obstruction and possible complications of recent cholecystectomy

63. Gallstone Ilius Unusual complication of chronic cholecystitis
-Impaction of gallstone in ileum after passing through a biliary-enteric fistula
-60% are cholecystoduodenal fistulae; others are cholecystocolonic and cholecystogastric fistulae
-Average age of patient is 70 years old
Delay in diagnosis:
Mortality of 15-20%
Rigler’s Triad:
Pneumobilia
SBO
Impacted gallstone-usually in the terminal ileum

64. Gallstone Ilius Unusual complication of chronic cholecystitis
-Impaction of gallstone in ileum after passing through a biliary-enteric fistula
-60% are cholecystoduodenal fistulae; others are cholecystocolonic and cholecystogastric fistulae
-Average age of patient is 70 years old
Delay in diagnosis:
Mortality of 15-20%
Rigler’s Triad:
Pneumobilia
SBO
Impacted gallstone-usually in the terminal ileum

65. Gallstone Ilius
Treatment
- same as for ileus (i.e. decompression)
- surgery

66. Final Thoughts
- US is initial test of choice
- HIDA most accurate
- Old people with biliary history and SBO, look for gallstone ileus

68. FIN