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

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

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

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

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

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)

Last update: 2022-06-13 16:53:22