Biliary Disease

Braden Vogt

Alex Wiles

Pearls

  • ERCP is not available at VA: requires fee-basis consult to VUMC, contact GI to arrange
  • Prior cholecystectomy -> CBD normally dilates to 10 mm, not pathologic
  • Pneuomobilia generally indicates performance of prior biliary sphincterotomy and/or biliary stent
  • CBD dilation classically > 6mm, but CBD dilates with age: 70 yo -> 7mm, 80 yo -> 8mm; opiates can also cause biliary dilatation

Acute Calculous Cholecystitis

  • Inflammation of the GB from an obstructing stone in the GB neck or cystic duct
  • Ddx: PUD, pancreatitis, choledocholithiasis, ascending cholangitis, IBD, Fitz-Hugh Curtis
  • Presentation: Severe constant RUQ pain, fever/chills, N/V, + Murphy sign
  • Evaluation: CBC (leukocytosis), CMP (mild AST/ALT ↑), Lipase, Lactate, BCx x2
  • Imaging: RUQ U/S: gallstones + GB wall thickening or pericholecystic edema
    • If U/S non-diagnostic (no stones or GB inflammation)à HIDA Scan (lack of GB filling)

Management: Supportive care, antibiotics, GB drainage

  • IVF, correct electrolyte abnormalities, NPO
  • Broad spectrum antibiotic coverage
  • Place CT-guided procedure consult for cholecystostomy placement vs Endoscopic drainage (transpapillary cystic duct stent via ERCP or cholecystoduodenostomy by EUS)
  • Consult EGS if necrosis, perforation, or emphysematous changes present

Management: NPO, IVF, IV Abx until resolved or surgical removal

  • Urgent Cholecystectomy (<72H) with EGS;
    • If poor surgical candidate: Cholecystostomy with IR; endoscopic drainage options for selected patients (i.e. poor surgical candidates also with ascites)
    • Complications: gangrenous cholecystitis, perforation, emphysematous cholecystitis, chole-cysto-enteric fistula, gallstone ileus

Acute Acalculous Cholecystitis

  • Inflammation of the GB without obstructing stone (due to stasis and ischemia)
  • Presentation: Seen in critically ill/ICU pts; similar history as above; may present as unexplained fever or RUQ mass (rarely jaundice)
  • Ddx: calculous cholecystitis, pancreatitis, hepatic abscess
  • Evaluation: Same as acute calculous cholecystitis
  • Imaging: GB wall thickening, pericholecystic edema, intramural gas, GB distention

Biliary Colic

  • Transient biliary obstruction typically at the GB neck without GB inflammation (no fever)
  • Presentation: Constant (not colicky) intense, dull RUQ pain and N/V for 30 minutes to 6 hours, then resolves, provoked by fatty foods (CCK), absent Murphy’s sign
  • Biliary colic generally consists of discrete episodes separated by weeks to months, and not daily pain
    • Evaluation: Normal (CBC, LFTs, Lipase, Lactate) - Imaging: RUQ U/S: cholelithiasis (stones in GB)
  • Management: Elective cholecystectomy as outpatient

Choledocholithiasis

Anton de Witte

Braden Vogt

  • Obstruction of biliary outflow by CBD stone without inflammation (no fever)
    • Impacted cystic duct stone (cholecystitis) with compression of the CBD (Mirizzi syndrome)
  • Presentation: RUQ pain (can be painless), N/V and jaundice
  • Evaluation: CMP and D-bili (Bili/ALP/ GGT ↑↑↑, AST/ALT mild ↑), CBC (Leukocytosis suggests cholangitis), Lipase
  • Imaging: RUQ U/S: dilated CBD (ULN is 6mm) à MRCP/EUS vs ERCP (see below)
    • MRCP preferred given non-invasive but has lower sensitivity for smaller stones (consider EUS if still have suspicion despite negative MRCP or if patient contraindication to/intolerance of MRI)

Approach to Choledocholithiasis:

Approach to risk stratification choledocholithiasis:

Risk Profile

Clinical and Imaging Features

High

CBD stone on imaging

Clinical Acute Cholangitis

Tbili > 4 AND dilated CBD (>6mm with GB, > 8mm without GB)

Intermediate

Abnormal liver enzymes

Age > 55

Dilated CBD on U/S with Tbili < 4

Low

No predictors present

Management

  • NPO & IVF, pain control PRN
  • Procedures as per above algorithm
  • See Cholangitis section If concern for acute cholangitis

Acute Cholangitis

  • Bacterial infection of biliary tract 2/2 obstruction (typically stones) or prior instrumentation (ERCP)
    • Pts with malignant obstruction typically do not develop cholangitis
  • Presentation: Charcot triad (RUQ pain, fever, jaundice); Reynolds’ Pentad (AMS, Hypotension)
  • Evaluation: CBC, CMP (D bili, ALP ↑↑↑) Blood Cultures, Lipase, Lactate o CRP, AST/ALT can be ↑↑ as well
  • Imaging: RUQ U/S: dilated CBD (ULN is 6mm), no need for MRCP/EUS
    • Consider MRCP overnight if ERCP is not being done emergently

Management

  • NPO, IVF
  • Consult GI for urgent/emergent ERCP (generally within 24 hr)
  • If ERCP not feasible or fails to establish biliary drainage, can consider EUS-guided biliary drainage, percutaneous transhepatic cholangiography, or surgical decompression
  • Antibiotics for Biliary Disease (IDSA Guidelines)
    • Mild to moderate acute cholecystitis (stable):
      • Ceftriaxone 2g daily, Cefazolin 1-2g q8H
    • Cholangitis or Severe acute cholecystitis (unstable or immunocompromised):
      • Zosyn 3.375g q8H, Meropenem 1g q8H or Cipro 500 q12H and Flagyl 500 q8H
      • Healthcare-associated Biliary infections: consider Vancomycin (order w/PK consult)
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