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Biliary Colic, Acute Cholecystitis, and Ascending Cholangitis

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Biliary Colic, Acute Cholecystitis, and Ascending Cholangitis Aims and objectives • Target audience: medical students in clinical years, and PAs • Duration: 60 minutes • Today: biliary colic, acute cholecystitis, and ascending cholangitis • Pathophysiology, clinical features, investigations, management, prognosis • Multi-step SBAs: for a full understanding of the patient journey • Summary and Q&A • Slides and previous recordings: app.bitemedicine.com 2 Case-based discussion: 1 History A 44-year-old Caucasian female presents to the emergency department with a 1-month history of intermittent right-sided abdominal pain, worse after eating a heavy meal. On examination, the abdomen is soft and non-tender. Observations HR 90, BP 128/89 mmHg, RR 16, SpO2 99%, Temp 37.2 6 Question Q1 Q2 Q3 Q4 Q5 Q6 What is the most likely diagnosis? Cholecystitis Common bile duct stone Biliary colic Cholangitis Mirizzi syndrome app.bitemedicine.com 7 Explanations Q1 Q2 Q3 Q4 Q5 Q6 What is the most likely diagnosis? Cholecystitis Associated with RUQ pain and tenderness on examination, +ve Murphy’s sign and fever Common bile duct stone Associated with obstructive symptoms (jaundice, dark urine, pale stools) or features of cholangitis Biliary colic Intermittent RUQ pain after a heavy meal in a high-risk group, apyrexial with few/no examination findings Cholangitis Associated with Charcot’s triad / Reynolds’ pentad Mirizzi syndrome Common hepatic duct obstruction caused by extrinsic compression; usually presents with jaundice, fever, and RUQ pain app.bitemedicine.com 9 Case-based discussion: 1 History A 44-year-old Caucasian female presents to the emergency department with a 1-month history of intermittent right-sided abdominal pain, worse after eating a heavy meal. On examination, the abdomen is soft and non-tender. Observations HR 90, BP 128/89 mmHg, RR 16, SpO2 99%, Temp 37.2 10 Gallstone disease (1) 11 Gallstone disease Definitions (NICE CKS, 2019) • A gallstone (cholelithiasis) is a solid deposit that forms within the gallbladder • Cholecystolithiasis describes gallstones in the gallbladder • Choledocholithiasis describes gallstones in the common bile duct (2) 12 Question Q1 Q2 Q3 Q4 Q5 Q6 Which of the following is true regarding gallstones? Mixed stones are the most common type of gallstone in the developed world 50% of gallstones are asymptomatic Cholesterol stones mainly affect those with sickle cell disease Anorexia is a risk factor for gallstones Gallstones affect 20% of the general population app.bitemedicine.com 13 Explanations Q1 Q2 Q3 Q4 Q5 Q6 Which of the following is true regarding gallstones? Mixed stones are the most common type of gallstone in the developed worlds Cholesterol stones are the most common in the developed world 50% of gallstones are asymptomatic 80% gallstones are asymptomatic Cholesterol stones mainly affect those with sickle cell disease Pigment stones mainly affect those with haemolytic disorders such as sickle cell disease Anorexia is a risk factor for gallstones Although rapid weight loss and fasting are risk factors, a low BMI itself is not Gallstones affect 20% of the general population Gallstone-related complications are the most common cause of GI admissions in Europe (EASL, 2016) app.bitemedicine.com 15 Gallstones Composition • Cholesterol: most common (80%) due to increased cholesterol, reduced bile salts and biliary stasis • Pigment: mainly affecting those with haemolytic disorders, or liver cirrhosis • Mixed (3) Cholesterol Mixed Pigment 16 Gallstones: pathophysiology • 80% of those with gallstones are asymptomatic, often for years Clinical features of gallstones • Biliary colic: as the gallbladder contracts against a stone lodged in the cystic duct • Acute cholecystitis: inflammation of the gallbladder • Ascending cholangitis: infection of the biliary tree, commonly due to CBD stone 17 Gallstone disease Biliary colic • Gallbladder contracts against stone impacted in cystic duct • Constant RUQ pain after heavy meal • No fever or abdominal tenderness (NICE CKS) (1) 18 Gallstone disease Acute cholecystitis • Inflammation of the gallbladder Calculous cholecystitis • Due to gallstone impacted at the neck of gallbladder or cystic duct à inflammation, bile stasis, bacterial overgrowth • RUQ tenderness, Murphy’s sign and fever (1) 19 Gallstone disease Acute cholecystitis • Inflammation of the gallbladder Acalculous cholecystitis (5-10%) • Usually in severely unwell patients • Secondary to hypovolaemia, trauma, or systemic illness à gallbladder stasis and blockage of bile ducts • Poor prognosis (1) 20 Gallstone disease Ascending cholangitis • Infection of the biliary tree • Usually due to stone which has moved into the CBD • Obstruction à cholestasis à infection (E. coli most common) • Other key causes: biliary strictures, cholangiocarcinoma, ERCP (4) 21 Question Q1 Q2 Q3 Q4 Q5 Q6 Which of the following is a risk factor for gallstone disease? Pregnancy South Asian ethnicity Male Metformin use Ulcerative colitis app.bitemedicine.com 22 Explanations Q1 Q2 Q3 Q4 Q5 Q6 Which of the following is a risk factor for gallstone disease? Pregnancy Gallstones are more common due to reduced gallbladder motility and more cholesterol saturation of bile South Asian ethnicity Caucasians are at high risk, as are Hispanic and Native-American ethnicities (NICE CKS, 2019) Male Females are 2-3x more likely to develop gallstones (NICE CKS, 2019) Metformin use Although diabetes is a risk factor, Metformin use is not associated with gallstone disease Ulcerative colitis Crohn’s disease cause bile acid malabsorption due to a terminal ileal disease à cholesterol supersaturated bile app.bitemedicine.com 24 Introduction to gallstone disease Epidemiology • Gallstones affect 10-20% of the general population (NICE CKS, 2019) • Gallstone-related complications are the most common cause of GI admissions in Europe (EASL, 2016) ‘4 F’s’: classic risk factors Female 2-3x more likely to develop gallstones Fat BMI >30 is a key risk factor Forties Risk increases significant from 40 years old Fertile Pregnancy is an important risk factor 25 Introduction to gallstone disease Other risk factors (NICE CKS, 2019) • Family history: particularly if first-degree relative • Rapid weight loss/prolonged fasting: if exceeding 1.5kg/week, e.g. bariatric surgery • Diabetes mellitus and NAFLD • Crohn’s disease: bile acid malabsorption due to a terminal ileal disease à cholesterol supersaturated bile • Medication: COCP, HRT, octreotride, GLP-1 analogues, ceftriaxone • Haemolytic conditions: e.g. sickle cell disease à pigment stones 26 Gallstone disease: clinical features (NICE CKS, 2019) Biliary colic Constant, steady RUQ or epigastric pain (not colicky) Severe abdominal pain >30 minutes, but <8hours, often worse after fatty meal Nausea and/or vomiting No fever and no abdominal tenderness 27 Case-based discussion: 2 History A 56-year-old Caucasian male presents to the emergency department with a 4-hour history of RUQ pain and fever. On examination, he is tender in the right upper quadrant and palpating the RUQ whilst the patient breathes in deeply causes significant pain. Observations HR 110, BP 119/88 mmHg, RR 17, SpO2 98%, Temp 38.9 28 Gallstone disease: clinical features (NICE CKS, 2019) Biliary colic Acute cholecystitis Constant, steady RUQ or Features similar to biliary epigastric pain (not colicky) colic Severe abdominal pain >30 Referred right shoulder tip minutes, but <8hours, often pain worse after fatty meal Nausea and/or vomiting Fever, tenderness in RUQ No fever and no abdominal Murphy’s sign positive tenderness 29 Gallstone disease: clinical features (NICE CKS, 2019) Biliary colic Acute cholecystitis Ascending cholangitis Constant, steady RUQ or Features similar to biliary Charcot’s triad: fever (often epigastric pain (not colicky) colic with rigors), jaundice, and RUQ pain Severe abdominal pain >30 Referred right shoulder tip Reynolds’ pentad: Charcot’s minutes, but <8hours, often pain triad + shock + altered mental worse after fatty meal status Nausea and/or vomiting Fever, tenderness in RUQ Obstructive features: e.g. pale stools/dark urine No fever and no abdominal Murphy’s sign positive tenderness 30 Question Q1 Q2 Q3 Q4 Q5 Q6 Which of the following conditions is associated with a raised serum conjugated bilirubin? Cholecystitis Biliary colic Cystic duct stone Ascending cholangitis Vesicoureteric junction stone app.bitemedicine.com 31 Explanations Q1 Q2 Q3 Q4 Q5 Q6 Which of the following conditions is associated with a raised serum conjugated bilirubin? Cholecystitis Bilirubin levels should be normal and patients should not be jaundiced Biliary colic Bilirubin levels should be normal and patients should not be jaundiced Cystic duct stone Usually results in biliary colic or cholecystitis, bilirubin levels should be normal Ascending cholangitis Most commonly due to CBD stone, resulting in obstructive jaundice (conjugated hyperbilirubinaemia) Vesicoureteric junction stone This is a type of renal stone, not gallstone app.bitemedicine.com 33 Investigations: biliary colic Primary investigations • Abdominal ultrasound: the first-line imaging investigation of choice to identify gallstones • Liver function tests: to identify evidence of biliary obstruction (raised ALP, bilirubin) (5) NICE CKS. Gallstone disease. (2019) and NICE (2014) 34 EASL. Clinical Practice Guidelines on the Diagnosis and Treatment of Gallstones (2016). Investigations: biliary colic Primary investigations • Abdominal ultrasound: the first-line imaging investigation of choice to identify gallstones • Liver function tests: to identify evidence of biliary
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