### Date : 2024-07-09 22:25 ### Topic : Biliary Tract Disorders #Medicine #internalmedicine ---- ### Acute Cholecystitis, Cholelithiasis, and Cholangitis **Acute Cholecystitis, Cholelithiasis, and Cholangitis** are three common biliary tract disorders. Understanding their definitions, pathophysiology, clinical features, diagnostic criteria, and management strategies is crucial for effective treatment. ### Acute Cholecystitis **Definition:** - Acute cholecystitis is the inflammation of the gallbladder, usually due to obstruction of the cystic duct by a gallstone. **Pathophysiology:** - **Obstruction:** Gallstone lodges in the cystic duct. - **Inflammation:** The blockage leads to inflammation, infection, and distention of the gallbladder. - **Ischemia:** Persistent obstruction can cause ischemia and necrosis of the gallbladder wall. **Clinical Features:** - **Pain:** Severe, steady right upper quadrant (RUQ) or epigastric pain that may radiate to the right shoulder or back. - **Murphy’s Sign:** Pain and inspiratory arrest upon palpation of the RUQ. - **Fever and Leukocytosis:** Indicating inflammation or infection. - **Nausea and Vomiting:** Common gastrointestinal symptoms. **Diagnosis:** - **Ultrasound:** First-line imaging showing gallbladder wall thickening, pericholecystic fluid, and gallstones. - **HIDA Scan:** Useful if ultrasound is inconclusive; shows gallbladder dysfunction. - **Laboratory Tests:** Elevated white blood cell count (WBC), liver enzymes, and C-reactive protein (CRP). **Management:** - **Hospital Admission:** For monitoring and supportive care. - **NPO (Nil Per Os):** Nothing by mouth to rest the gallbladder. - **Intravenous Fluids:** To maintain hydration and electrolyte balance. - **Antibiotics:** Broad-spectrum antibiotics to cover Gram-negative and anaerobic bacteria. - **Pain Management:** NSAIDs or opioids for pain relief. - **Cholecystectomy:** Surgical removal of the gallbladder, typically performed laparoscopically, is the definitive treatment. ### Cholelithiasis **Definition:** - Cholelithiasis refers to the presence of gallstones in the gallbladder. **Pathophysiology:** - **Formation:** Gallstones form from the precipitation of cholesterol, bilirubin, or a mixture of these substances in the bile. - **Types:** Cholesterol stones (most common in the Western world) and pigment stones (common in conditions causing hemolysis). **Clinical Features:** - **Asymptomatic:** Many individuals with gallstones remain asymptomatic. - **Biliary Colic:** Episodic, severe RUQ pain, often after fatty meals, due to temporary obstruction of the cystic duct by a gallstone. **Diagnosis:** - **Ultrasound:** The preferred imaging modality to detect gallstones and assess the gallbladder. - **Oral Cholecystography and CT Scan:** Less commonly used but can provide additional information. **Management:** - **Asymptomatic Stones:** Generally require no treatment. - **Symptomatic Stones:** - **Pain Management:** NSAIDs or opioids for biliary colic. - **Elective Cholecystectomy:** Recommended to prevent recurrent symptoms and complications. - **Non-Surgical Options:** Oral bile acids (e.g., ursodeoxycholic acid) to dissolve cholesterol stones in patients who are not surgical candidates. ### Cholangitis **Definition:** - Cholangitis is an infection of the bile ducts, usually due to bacterial infection secondary to bile duct obstruction. **Pathophysiology:** - **Obstruction:** Commonly caused by gallstones, strictures, or tumors obstructing the bile duct. - **Infection:** Stagnant bile becomes infected by bacteria ascending from the duodenum, leading to inflammation and infection of the bile ducts. **Clinical Features:** - **Charcot’s Triad:** - **Fever:** With chills. - **RUQ Pain:** Severe and constant. - **Jaundice:** Yellowing of the skin and eyes due to bile duct obstruction. - **Reynolds’ Pentad (severe cases):** - **Hypotension:** Indicating sepsis. - **Altered Mental Status:** Due to severe infection and sepsis. **Diagnosis:** - **Ultrasound:** To detect bile duct dilation and the presence of stones. - **ERCP (Endoscopic Retrograde Cholangiopancreatography):** Both diagnostic and therapeutic, allowing visualization and removal of bile duct stones. - **MRCP (Magnetic Resonance Cholangiopancreatography):** Non-invasive imaging to visualize the biliary tree. - **Laboratory Tests:** Elevated WBC, liver enzymes (ALP, GGT, bilirubin), and blood cultures. **Management:** - **Hospital Admission:** For monitoring and supportive care. - **Intravenous Fluids and Antibiotics:** To manage infection and sepsis. - **Biliary Decompression:** Via ERCP, percutaneous transhepatic cholangiography (PTC), or surgery to relieve obstruction. - **Definitive Treatment:** Address the underlying cause of obstruction, often involving cholecystectomy if gallstones are the cause. ### Conclusion Understanding the definitions, pathophysiology, clinical features, diagnostic criteria, and management strategies for acute cholecystitis, cholelithiasis, and cholangitis is essential for effectively treating these common biliary tract disorders. Prompt diagnosis and appropriate intervention can prevent complications and improve patient outcomes.