Difference between revisions of "Choledocholithiasis"

(Differential Diagnosis)
(Evaluation: Change CBD normal valus)
 
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==Background==
 
==Background==
The biliary system includes the hepatic bile canaliculi, intrahepatic ducts, extrahepatic ducts, the gall bladder, the cystic duct, and the common bile duct. The liver produces bile, which is not only a byproduct of red blood cell breakdown, but also aids in digestion. The gallbladder stores bile until stimulated, upon which bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.
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*Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
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. It is these stones that cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
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*If infected, becomes [[Cholangitis]]
Choledocholithiasis occurs when a stone is expelled out of the gallbladder and becomes impacted in the common bile duct.
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{{Gallbladder background}}
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{{Gallbladder disease types}}
  
 
==Clinical Features==
 
==Clinical Features==
RUQ pain - early pain characterized as colicky (intermittent, comes and goes), once impacted, is constant and severe
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*[[RUQ pain]]
Nausea and Vomiting
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**Radiation to the right shoulder (phrenic nerve irritation)
Radiation to the Right shoulder - phrenic nerve irritation
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**Early pain characterized as colicky, intermittent
Jaundice and Scleral icterus - caused by build up of direct bilirubin in blood
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**Once impacted, is constant and severe
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*[[Nausea and Vomiting]]
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*[[Jaundice]]/scleral icterus  
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**Caused by buildup of direct bilirubin in blood
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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**[[Symptomatic cholelithiasis]]/[[Biliary Colic]]
 
**[[Symptomatic cholelithiasis]]/[[Biliary Colic]]
 
**[[Acalculous cholecystitis]]
 
**[[Acalculous cholecystitis]]
**[[Gallstone Pancreatitis]]
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**[[Gallstone pancreatitis]]
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**[[Choledocholithiasis]]
 
*[[Peptic ulcer disease]] with or without perforation
 
*[[Peptic ulcer disease]] with or without perforation
 
*[[Pancreatitis]]
 
*[[Pancreatitis]]
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==Evaluation==
 
==Evaluation==
Labs
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*[[LFTs]], lipase, and basic chemistry
*Particularly LFTs, Lipase, and Basic Chemistry
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*Imaging
Imaging
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**[[RUQ Ultrasound]]
*Ultrasound of RUQ - Noninvasive and quick, CBD >6mm (inner to inner wall) or Age/100 cm when >60 years old
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***Noninvasive and quick
*ERCP - highly sensitive and specific, also therapeutic
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***Common bile duct < 6 mm plus 1mm per decade after 60 yrs old
*MRCP - comparable to ERCP in Sn/Sp
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***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)
*HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder
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**ERCP - highly sensitive and specific, also therapeutic
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**MRCP - comparable sensitivity/specificity to ERCP
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**HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder
  
 
==Management==
 
==Management==
*Pain relief
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*[[Pain control]]
*Fluid and electrolyte repletion
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*[[Fluid resuscitation]] and [[electrolyte repletion]]
 
*NPO
 
*NPO
*If any concern for concomitant acute cholecystitis, start antibiotics
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*If any concern for concomitant [[acute cholecystitis]], start antibiotics
**Always consider [[Cholangitis]]
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**Always consider [[cholangitis]]
  
 
==Disposition==
 
==Disposition==
 
*Admission to medical services
 
*Admission to medical services
 
**Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management
 
**Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management
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**Strong predictors for choledocholithiasis on ERCP<ref>Magalhaes J et al. Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice. Feb 2015. World J Gastrointest Endosc. 2015 Feb 16; 7(2): 128–134.</ref>:
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***Clinical ascending [[cholangitis]]
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***CBD stones on US
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***Total bilirubin > 4 mg/dL
  
 
==See Also==
 
==See Also==
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*[[Gallbladder disease (main)]]
  
 
==External Links==
 
==External Links==
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==References==
 
==References==
 
<references/>
 
<references/>
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[[Category:GI]]

Latest revision as of 10:46, 5 May 2019

Background

  • Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
  • If infected, becomes Cholangitis

Anatomy & Pathophysiology

Gallbladder anatomy
  • 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

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

Evaluation

  • LFTs, lipase, and basic chemistry
  • Imaging
    • RUQ Ultrasound
      • Noninvasive and quick
      • Common bile duct < 6 mm plus 1mm per decade after 60 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

Management

Disposition

  • Admission to medical services
    • Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management
    • Strong predictors for choledocholithiasis on ERCP[1]:
      • Clinical ascending cholangitis
      • CBD stones on US
      • Total bilirubin > 4 mg/dL

See Also

External Links

References

  1. Magalhaes J et al. Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice. Feb 2015. World J Gastrointest Endosc. 2015 Feb 16; 7(2): 128–134.