Biliary tract diseases resident survival guide: Difference between revisions

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{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | | B02 | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Asymptomatic:'''<br> Gallstones identified during<br> ❑ Imaging evaluation of abdominal and pelvic diseases<br> ❑ Palpation of gallbladder at operation </div>|B02=<div style="float: left; text-align: left; line-height: 150% ">'''Symptomatic:'''<br> ❑ Abdominal pain </div> }}
{{familytree | | | | | | | | | B01 | | | | | | B02 | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Asymptomatic:'''<br> Gallstones identified during<br> ❑ Imaging evaluation of abdominal and pelvic diseases<br> ❑ Palpation of gallbladder at operation </div>|B02=<div style="float: left; text-align: left; line-height: 150% ">'''Symptomatic:'''<br> ❑ Abdominal pain </div>}}
{{familytree | | | | | | | | | |!| | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | |!| | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | C01 | | |,|-|-|-|^|-|-|-|.| | | | |C01='''Asymptomatic cholelithiasis'''}}
{{familytree | | | | | | | | | C01 | | |,|-|-|-|^|v|-|-|-|.| | | | |C01='''Asymptomatic cholelithiasis'''}}
{{familytree | | | | | | | | | |!| | | |!| | | | | | | |!| | | |}}
{{familytree | | | | | | | | | |!| | | |!| | | | |!| | | |!| | | |}}
{{familytree | | | | | | | | | D01 | | D02 | | | | | | D03 | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">❑ Observation<br>❑ Expectant management<br>❑ Prophylactic cholecystectomy</div>|D02=<div style="float: left; text-align: left; line-height: 150% ">❑ Biliary colic<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
{{familytree | | | | | | | | | D01 | | D02 | | | D03 | | D04 | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">❑ Observation<br>❑ Expectant management<br>❑ Prophylactic cholecystectomy</div>|D02=<div style="float: left; text-align: left; line-height: 150% ">❑ Biliary colic<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ Right upper quadrant or epigastric or substernal pain
:❑ Right upper quadrant or epigastric or substernal pain
:❑ Sharp, intermittent and cramping pain
:❑ Sharp, intermittent and cramping pain
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:❑ Pain associated with diaphoresis
:❑ Pain associated with diaphoresis
:❑ Pain associated with fever
:❑ Pain associated with fever
:❑ Pain associated with anorexia</div></div>  
:❑ Pain associated with anorexia</div></div> </div>|D04=<div style="float: left; text-align: left; line-height: 150% ">'''Atypical symptoms:'''<br>❑ Diffuse abdominal pain<br>❑ Retrosternal heart burn<br>❑ Fluid regurgitation<br>❑ Belching<br>❑ Abdominal distension/bloating<br>❑ Early satiety/fullness after meals</div>}}
<br>❑ Diffuse abdominal pain<br>❑ Retrosternal heart burn<br>❑ Fluid regurgitation<br>❑ Belching<br>❑ Abdominal distension/bloating<br>❑ Early satiety/fullness after meals</div>}}
{{familytree | | | | | | | | | | | | | |!| | | | |!| | | |!| | | |}}
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | | | | E01 | | | E02 | | E03 | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<br>❑ No significant findings</div>|E02=Examine the patient|E03=Examine the patient}}
{{familytree | | | | | | | | | | | | | E01 | | | | | | E02 | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<br>❑ No significant findings</div>|E02=Further evaluation for alternate diagnosis}}
{{familytree | | | | | | | | | | | | | |!| | | | |!| | | |!| | | |}}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | F01 | | | F02 | | F03 | | | | |F01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase</div>|F02=<div style="float: left; text-align: left; line-height: 150% ">'''Consider:'''<br>❑ Evaluation for cholelithiasis associated complications<br>❑ Evaluation for choledocholithiasis associated complications</div>|F03=<div style="float: left; text-align: left; line-height: 150% ">'''Consider:'''<br>❑ Evaluation for alternate diagnosis</div>}}
{{familytree | | | | | | | | | | | | | F01 | | | | | | | | | | | |F01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ Serum total bilirubin<br>❑ AST<br>❑ ALT<br>❑ Serum alkaline phosphatase<br>❑ GGT<br>❑ Serum amylase<br>❑ Serum lipase</div>}}
{{familytree | | | | | | | | | | | | | |!| | | | |!| | | |!| | | |}}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | G01 | | | G02 | | G03 | | | | | |G01='''Order transabdominal USG (TAUSG)'''|G02=<div style="float: left; text-align: left; line-height: 150% ">'''Include:'''<br>❑ CBC<br>❑ BMP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase<br>❑ TAUSG<BR>❑ HIDA<BR>❑ EUS/MRCP<BR>❑ ERCP<BR>❑ Blood C & S</div>|G03=<div style="float: left; text-align: left; line-height: 150% ">'''Include:'''<br>❑ CBC<br>❑ BMP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase<br>❑ Urine analysis<br>❑ EKG<br>❑ CXR<br>❑ Esophageal manometry<br>❑ UGI endoscopy<br>❑ CT abdomen</div>}}
{{familytree | | | | | | | | | | | | | G01 | | | | | | | | | | | |G01='''Order transabdominal USG (TAUSG)'''}}
{{familytree | | | | | | | | | | | | | |!| | | | |!| | | |!| | |}}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | H01 | | | H02 | | H03 | | | |H01=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic criteria:'''<br>❑ Biliary colic<br>❑ No significant findings during PE<BR>❑ Normal CBC, LFT & pancreatic enzymes<br>❑ Gallstones/biliary sludge during TAUSG </div>|H02=Manage accordingly|H03=Manage accordingly}}  
{{familytree | | | | | | | | | | | | | H01 | | | | | | | | | | | |H01=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic criteria:'''<br>❑ Biliary colic<br>❑ No significant findings during PE<BR>❑ Normal CBC, LFT & pancreatic enzymes<br>❑ Gallstones/biliary sludge during TAUSG </div>}}  
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | |}}
{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | |}}
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{{familytree | | | | | | | | | J01 |-|`| | J02 | | J03 | |J01=<div style="float: left; text-align: left; line-height: 150% ">Acute pain management
{{familytree | | | | | | | | | J01 |-|`| | J02 | | J03 | |J01=<div style="float: left; text-align: left; line-height: 150% ">Acute pain management
:❑ Ketorolac 30-60 mg IM/IV single dose  
:❑ Ketorolac 30-60 mg IM/IV single dose  
:❑ Follow with 400 mg ibuprofen/opioids until cholecystectomy</div>|J02=w/ classical biliary colic|J03=w/o classical biliary colic}}
:❑ Follow with 400 mg ibuprofen/opioids until cholecystectomy</div>|J02=w/ classical biliary colic|J03=w/o classical biliary colic ± atypical symptoms}}
{{familytree | | | | | | |,|-|-|^|.| |!| | |!| | | |!| |}}
{{familytree | | | | | | |,|-|-|^|.| |!| | |!| | | |!| |}}
{{familytree | | | | | | K01 | | K02 |!| | K03 | | K04 |K01=Poor surgical candidates|K02=Good surgical candidates|K03=Repeat TAUSG in few weeks (especially for <3 mm stones)|K04=Further evaluation for abdominal pain}}
{{familytree | | | | | | K01 | | K02 |!| | K03 | | K04 |K01=Poor surgical candidates|K02=Good surgical candidates|K03=Repeat TAUSG in few weeks (especially for <3 mm stones)|K04=Consider evaluation for alternate diagnosis of abdominal pain}}
{{familytree | | | | | | |!| | | |!| |!| |,|^|-|-|-|.|}}
{{familytree | | | | | | |!| | | |!| |!| |,|^|-|-|-|.|}}
{{familytree | | | | | | L01 | | L02 |`|-| L03 | | L04 |L01=Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years/more|L02=Laparoscopic cholecystectomy (as early as possible to avoid gallstone related complications)|L03=Gallstones/biliary sludge during TAUSG|L04= No gallstones/biliary sludge during TAUSG}}
{{familytree | | | | | | L01 | | L02 |`|-| L03 | | L04 |L01=Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years/more|L02=Laparoscopic cholecystectomy (as early as possible to avoid gallstone related complications)|L03=Gallstones/biliary sludge during TAUSG|L04= No gallstones/biliary sludge during TAUSG}}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | M01 |M01=HIDA scan}}
{{familytree | | | | | | | | | | | | | | | | | | | M01 | | |M01=Cholecystokinin stimulated HIDA scan}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | | |}}
{{familytree | | | | | N01 |-| N02 |-| N03 |-| N04 | | N05 |-|N06|-|N07|N01=Cholecystectomy|N02='''Microlithiasis'''|N03=EUS|N04=GBEF >40%|N05=GBEF <40%|N06='''Functional Gallbladder disorder'''|N07=Chloecystectomy}}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | O01 | | | | | | | | | | | |O01=Consider evaluation for alternate diagnosis of abdominal pain}}

Revision as of 23:05, 6 January 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Cholelithiasis

Definitions

Terms Definitions
Cholelithiasis (gallstones) Cholelithiasis (gallstones) are crystallized pieces of bile including cholesterol and bilirubin in the gallbladder, which can range from microscopic to more than one inch in size and from one stone to hundreds in number.
Microlithiasis (biliary sludge) Microlithiasis (biliary sludge) are crystals and stones in the gallbladder that are too small to see with the naked eye.
Asymptomatic (incidential) cholelithiasis Asymptomatic (incidential) cholelithiasis refers to incidentally detected gallstones during routine ultrasound for other abdominal conditions or occasionally by palpation of the gallbladder at operation in patients who do not have any abdominal symptoms or have symptoms that are not thought to be due to gallstones.
Symptomatic and uncomplicated cholelithiasis Symptomatic and uncomplicated cholelithiasis refers to stones in the gallbladder that are associated with biliary colic in the absence of complications such as acute cholecystitis, cholangitis, or gallstone pancreatitis.
Symptomatic and complicated cholelithiasis Symptomatic and complicated cholelithiasis refers to stones in the gallbladder that are associated with upper abdominal pain, not typical of biliary colic in the presence of complications such as acute cholecystitis, cholangitis, or gallstone pancreatitis.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Asymptomatic
❑ Symptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic:
Gallstones identified during
❑ Imaging evaluation of abdominal and pelvic diseases
❑ Palpation of gallbladder at operation
 
 
 
 
 
Symptomatic:
❑ Abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic cholelithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Observation
❑ Expectant management
❑ Prophylactic cholecystectomy
 
❑ Biliary colic
❑ Right upper quadrant or epigastric or substernal pain
❑ Sharp, intermittent and cramping pain
❑ Pain for at least 30 minutes (but <6 hours)
❑ Pain radiating to right shoulder blade
❑ Pain after food intake
❑ Pain not aggravated by movements
❑ Pain associated with nausea, vomiting and diaphoresis
❑ H/o recurrent attacks ranging from hours to years
 
 
❑ Abdominal pain not typical of biliary colic
❑ Right upper quadrant or epigastric or substernal pain
❑ Sharp, severe and steady pain
❑ Pain for >6 hours
❑ Pain radiating to right shoulder blade
❑ Pain after food intake
❑ Pain aggravated by movements
❑ Pain associated with nausea & vomiting
❑ Pain associated with diaphoresis
❑ Pain associated with fever
❑ Pain associated with anorexia
 
Atypical symptoms:
❑ Diffuse abdominal pain
❑ Retrosternal heart burn
❑ Fluid regurgitation
❑ Belching
❑ Abdominal distension/bloating
❑ Early satiety/fullness after meals
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ No significant findings
 
 
Examine the patient
 
Examine the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
❑ CBC
❑ BMP
❑ Total bilirubin
❑ Direct bilirubin
❑ Albumin
❑ AST
❑ ALT
❑ Alkaline phosphatase
❑ GGT
❑ Amylase
❑ Lipase
 
 
Consider:
❑ Evaluation for cholelithiasis associated complications
❑ Evaluation for choledocholithiasis associated complications
 
Consider:
❑ Evaluation for alternate diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order transabdominal USG (TAUSG)
 
 
Include:
❑ CBC
❑ BMP
❑ Total bilirubin
❑ Direct bilirubin
❑ Albumin
❑ AST
❑ ALT
❑ Alkaline phosphatase
❑ GGT
❑ Amylase
❑ Lipase
❑ TAUSG
❑ HIDA
❑ EUS/MRCP
❑ ERCP
❑ Blood C & S
 
Include:
❑ CBC
❑ BMP
❑ Total bilirubin
❑ Direct bilirubin
❑ Albumin
❑ AST
❑ ALT
❑ Alkaline phosphatase
❑ GGT
❑ Amylase
❑ Lipase
❑ Urine analysis
❑ EKG
❑ CXR
❑ Esophageal manometry
❑ UGI endoscopy
❑ CT abdomen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:
❑ Biliary colic
❑ No significant findings during PE
❑ Normal CBC, LFT & pancreatic enzymes
❑ Gallstones/biliary sludge during TAUSG
 
 
Manage accordingly
 
Manage accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Meets diagnostic criteria:
Symptomatic & Uncomplicated cholelithiasis
 
 
 
 
 
Does not meet diagnostic criteria:
❑ No gallstones/biliary sludge during TAUSG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute pain management
❑ Ketorolac 30-60 mg IM/IV single dose
❑ Follow with 400 mg ibuprofen/opioids until cholecystectomy
 
 
 
 
w/ classical biliary colic
 
w/o classical biliary colic ± atypical symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Poor surgical candidates
 
Good surgical candidates
 
 
 
Repeat TAUSG in few weeks (especially for <3 mm stones)
 
Consider evaluation for alternate diagnosis of abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years/more
 
Laparoscopic cholecystectomy (as early as possible to avoid gallstone related complications)
 
 
 
Gallstones/biliary sludge during TAUSG
 
No gallstones/biliary sludge during TAUSG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cholecystokinin stimulated HIDA scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cholecystectomy
 
Microlithiasis
 
EUS
 
GBEF >40%
 
GBEF <40%
 
Functional Gallbladder disorder
 
Chloecystectomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider evaluation for alternate diagnosis of abdominal pain