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Biliary Disease

Alex Wiles, Anton de Witte

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
  • Pneumobilia 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

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

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) HIDA Scan (lack of GB filling)
  • 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
  • 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

Choledocholithiasis

  • 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) 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)
  • Management:
    • NPO & IVF, pain control PRN
    • Stratify risk to determine whether to pursue MRCP (noninvasive, diagnostic) vs ERCP
    • If any one of the following, patient is HIGH risk consult GI for ERCP + EGS to consider cholecystectomy
      • CBD stone on imaging
      • Acute cholangitis
      • Tbili > 4 AND dilated CBD (>6mm with GB, > 8mm without GB)
    • If any one of the following, patient is INTERMEDIATE risk consider MRCP (or EUS or cholecystectomy with intraoperative cholangiogram)
      • Abnormal liver enzymes
      • Age > 55
      • Dilated CBD on U/S with Tbili < 4
      • If CBD stone seen on MRCP or EUS ERCP,
      • If no CBD stone but patient has GB sludge or cholelithiasis EGS consult for cholecystectomy + intraoperative cholangiogram

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
    • 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)