Choledocholithiasis: Difference between revisions
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==Background== | ==Background== | ||
* | *Occurs when stone expelled from gallbladder becomes impacted in the common bile duct | ||
*If infected, becomes [[Cholangitis]] | *If infected, becomes [[Cholangitis]] | ||
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==Clinical Features== | ==Clinical Features== | ||
*[[RUQ pain]] | *[[RUQ pain]] | ||
**Radiation to the | **Radiation to the right shoulder (phrenic nerve irritation) | ||
**Early pain characterized as colicky | **Early pain characterized as colicky, intermittent | ||
**Once impacted, is constant and severe | **Once impacted, is constant and severe | ||
*[[Nausea and Vomiting]] | *[[Nausea and Vomiting]] | ||
*[[Jaundice]]/scleral icterus | *[[Jaundice]]/scleral icterus | ||
**Caused by | **Caused by buildup of direct bilirubin in blood | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 42: | Line 42: | ||
==Evaluation== | ==Evaluation== | ||
*[[LFTs]], lipase, and basic chemistry | |||
* | *Imaging | ||
Imaging | **[[RUQ Ultrasound]] | ||
*Ultrasound | ***Noninvasive and quick | ||
**Noninvasive and quick | ***Common bile duct < 4 mm plus 1mm per decade after 40 yrs old | ||
**Common bile duct < 4 mm plus 1mm per decade after 40 yrs old | ***US is highly sensitive and specific for [[acute cholecystitis]], much less sensitive/specific in identifying cholelithiasis due to exam limitations (i.e. difficulty identifying the CBD) | ||
** | **ERCP - highly sensitive and specific, also therapeutic | ||
*ERCP - highly sensitive and specific, also therapeutic | **MRCP - comparable sensitivity/specificity to ERCP | ||
*MRCP - comparable to ERCP | **HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder | ||
*HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder | |||
==Management== | ==Management== | ||
*Pain | *[[Pain control]] | ||
*Fluid and electrolyte repletion | *[[Fluid resuscitation]] and [[electrolyte repletion]] | ||
*NPO | *NPO | ||
*If any concern for concomitant acute cholecystitis, start antibiotics | *If any concern for concomitant [[acute cholecystitis]], start antibiotics | ||
**Always consider [[ | **Always consider [[cholangitis]] | ||
==Disposition== | ==Disposition== | ||
Revision as of 19:05, 12 July 2017
Background
- Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
- If infected, becomes Cholangitis
Anatomy & Pathophysiology
- Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
- These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
- Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.
Gallbladder disease types
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Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.
- Symptomatic cholelithiasis (biliary colic)
- Choledocholithiasis
- Acute calculous cholecystitis
- Ascending cholangitis
- Acalculous cholecystitis
- Biliary atresia
- Cholestasis of pregnancy
Clinical Features
- RUQ pain
- Radiation to the right shoulder (phrenic nerve irritation)
- Early pain characterized as colicky, intermittent
- Once impacted, is constant and severe
- Nausea and Vomiting
- Jaundice/scleral icterus
- Caused by buildup of direct bilirubin in blood
Differential Diagnosis
RUQ Pain
- Gallbladder disease
- Peptic ulcer disease with or without perforation
- Pancreatitis
- Acute hepatitis
- Pyelonephritis
- Pneumonia
- Kidney stone
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Fitz-Hugh-Curtis Syndrome
- Hepatomegaly due to CHF
- Herpes zoster
- Myocardial ischemia
- Bowel obstruction
- Pulmonary embolism
- Abdominal aortic aneurysm
Evaluation
- LFTs, lipase, and basic chemistry
- Imaging
- RUQ Ultrasound
- Noninvasive and quick
- Common bile duct < 4 mm plus 1mm per decade after 40 yrs old
- US is highly sensitive and specific for acute cholecystitis, much less sensitive/specific in identifying cholelithiasis due to exam limitations (i.e. difficulty identifying the CBD)
- ERCP - highly sensitive and specific, also therapeutic
- MRCP - comparable sensitivity/specificity to ERCP
- HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder
- RUQ Ultrasound
Management
- Pain control
- Fluid resuscitation and electrolyte repletion
- NPO
- If any concern for concomitant acute cholecystitis, start antibiotics
- Always consider cholangitis
Disposition
- Admission to medical services
- Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management