Chapter 54 / Biliary Tract 373

What is the major feared	Pancreatitis
complication of ERCP?
ACUTE CHOLECYSTITIS

What is the pathogenesis of acute cholecystitis?

Obstruction of cystic duct leads to inflammation of the gallbladder; 95% of cases result from calculi, and 5% from acalculous obstruction

What are the risk factors?	Gallstones
What are the signs and	Unrelenting RUQ pain or tenderness
symptoms?	Fever
	Nausea/vomiting
	Painful palpable gallbladder in 33%
	Positive Murphy’s sign
	Right subscapular pain (referred)
	Epigastric discomfort (referred)

What is Murphy’s sign?

What are the complications of acute cholecystitis?

What lab results are associated with acute cholecystitis?

What is the diagnostic test of choice for acute cholecystitis?

What are the signs of acute cholecystitis on ultrasound?

Acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration

Abscess Perforation Choledocholithiasis

Cholecystenteric fistula formation Gallstone ileus

Increased WBC; may have: Slight elevation in alkaline

phosphatase, LFTs

Slight elevation in amylase, T. Bili

Ultrasound

Thickened gallbladder wall ( 3 mm) Pericholecystic fluid

Distended gallbladder

Gallstones present/cystic duct stone Sonographic Murphy’s sign (pain on inspiration after placement of

ultrasound probe over gallbladder)

374 Section II / General Surgery

What is the difference between acute cholecystitis and biliary colic?

What is the treatment of acute cholecystitis?

What are the steps in lap chole (6)?

Biliary colic has temporary pain; acute cholecystitis has pain that does not resolve, usually with elevated WBCs, fever, and signs of acute inflammation on U/S

IVFs, antibiotics, and cholecystectomy early

1.Dissection of peritoneum overlying the cystic duct and artery

2.Clipping of cystic artery and transect

3.Division of cystic duct between clips

4.Dissection of gallbladder from the liver bed

5.Cauterization; irrigation; suction, to obtain hemostasis of the liver bed

6.Removal of the gallbladder through the umbilical trocar site

How is an IOC performed?

1.Place a clip on the cystic duct– gallbladder junction

2.Cut a small hole in the distal cystic duct to cannulate

3.Inject half-strength contrast and take an x-ray or fluoro

What percentage of patients 10% has an accessory cystic

artery?

Why should the gallbladder Looking for gallbladder cancer, anatomy specimen be opened in the

operating room?

ACUTE ACALCULOUS CHOLECYSTITIS

What is it?	Acute cholecystitis without evidence of
	stones
What is the pathogenesis?	It is believed to result from sludge and
	gallbladder disuse and biliary stasis,
	perhaps secondary to absence of
	cholecystokinin stimulation (decreased
	contraction of gallbladder)

	Chapter 54 / Biliary Tract 375
What are the risk factors?	Prolonged fasting
	TPN
	Trauma
	Multiple transfusions
	Dehydration
	Often occurs in prolonged postoperative
	or ICU setting

What are the diagnostic tests of choice?

1.Ultrasound; sludge and inflammation usually present with acute acalculous cholecystitis

2.HIDA scan

What are the findings on	Nonfilling of the gallbladder
HIDA scan?
What is the management	Cholecystectomy, or cholecystostomy
of acute acalculous	tube if the patient is unstable (placed
cholecystitis?	percutaneously by radiology or open
	surgery)
CHOLANGITIS
What is it?	Bacterial infection of the biliary tract
	from obstruction (either partial or
	complete); potentially life-threatening
What are the common	Choledocholithiasis
causes?	Stricture (usually postoperative)
	Neoplasm (usually ampullary carcinoma)
	Extrinsic compression (pancreatic
	pseudocyst/pancreatitis)
	Instrumentation of the bile ducts (e.g.,
	PTC/ERCP)
	Biliary stent

What is the most common cause of cholangitis?

What are the signs and symptoms?

Gallstones in common bile duct (choledocholithiasis)

Charcot’s triad: fever/chills, RUQ pain, and jaundice

Reynold’s pentad: Charcot’s triad plus altered mental status and shock

What lab results are associated with cholangitis?

Increased WBCs, bilirubin, and alkaline phosphatase, positive blood cultures

376 Section II / General Surgery
Which organisms are most	Gram-negative organisms (E. coli,
commonly isolated with	Klebsiella, Pseudomonas, Enterobacter,
cholangitis?	Proteus, Serratia) are the most common
	Enterococci are the most common
	gram-positive bacteria
	Anaerobes are less common (B. fragilis
	most frequent)
	Fungi are even less common (Candida)
What are the diagnostic tests	Ultrasound and contrast study (e.g., ERCP
of choice?	or IOC) after patient has “cooled off” with
	IV antibiotics
What is suppurative	Severe infection with sepsis—“pus under
cholangitis?	pressure”
What is the management of	Nonsuppurative: IVF and antibiotics,
cholangitis?	with definitive treatment later (e.g.,
	lap chole /– ERCP)
	Suppurative: IVF, antibiotics, and
	decompression; decompression can be
	obtained by ERCP with papillotomy,
	PTC with catheter drainage, or
	laparotomy with T-tube placement
SCLEROSING CHOLANGITIS
What is it?	Multiple inflammatory fibrous
	thickenings of bile duct walls resulting in
	biliary strictures

What is its natural history?

Progressive obstruction possibly leading to cirrhosis and liver failure; 10% of patients will develop cholangiocarcinoma

What is the etiology?

What is the major risk factor?

What type of IBD is the most common risk factor?

Unknown, but probably autoimmune

Inflammatory bowel disease

Ulcerative colitis ( 66%)