During this 20-25 minute pre-recorded lecture, Dr. Tina Park discusses the topic of gallstones. This in-depth review will provide an update on this topic for your clinical practice as well as supplement your learning for the ABIM Gastroenterology and Hepatology boards. CME pre-requiste of live Q & A webinar, 8th Annual Mount Sinai Intensive Board Review in Gastroenterology & Hepatology on Sept 29.
Okay. Hello. My name is Tina Park and today I'll be talking to you about golf stones and gall bladder diseases. Does account for approximately 10% of the museum. I have several questions prepare for you. So let's get started question number one. This is a 40 year old man who presents with intermittent postprandial right upper quadrant pain, nausea, vomiting and fever secondary to acute colds, cystitis. His white blood cell count is 12 and all of teas and light pace are both normal. He undergoes laproscopic als mastectomy And Post Update # two. He has the fees, abdominal pain and fever. He has a local psychosis. Now with white blood cell count of 16 LFTs are elevated total bilirubin up to A S. T 1 88 lT 200 Auckland Foster taste 1 90 how to skin shows the following images on the right. What is the next best step in management? A check a viral hepatitis panel be obtained ultrasound of the abdomen. C obtain M. R. C. P. Or the perform E R C. P. The correct answer is D. E. R. C. P hydrogen is a noninvasive tool that can demonstrate a via leak as you can see on the photos on the right there is trace or accumulation and the psychopathic space and in the right Caricola quarter Buy only can occur after college mastectomy and it's incidents is thought to be approximately 1% or less coolest aspect to me is the most frequent cause of bio duck injury. However, biologists can also occur after liver transplantation. Partial help protect the knee and trauma symptoms can be very non specific ranging anywhere from mild abdominal pain to very severe abdominal pain. Patients may develop nausea, vomiting or fever. If they have a JP drain, there should be bilious fluid draining through the J. P. And patients often have normal LFTs prior to surgery and then elevated LFTs post surgery. In serious cases, some patients may develop peritonitis or by Loma causing infection and sepsis potential sites of by a lake includes cystic duct system right into the paddock duck branch, uncommon a paddock doctor on the right here is a picture of a cool angiogram during an ERCP demonstrating Abaya League. The contrast fills the common bile duct and some of the internet paddock ducts, but there is extra visitation of contrast into the gallbladder fossa near the JP drain E. R. C. P. Was spent around me. And common bile duct stent placement is recommended to treat the by a league. This helps divert the flow of bile away from the peritoneum and into the duodenum allows the site of the bile duct injury to heal E. R. c. p. is effective in more than 90% of cases. For those who do not respond to stand therapy, they may require hypocritical judgment Ostuni and for patients with very large calculated collections that may be infected, they may benefit from for continuous drainage. For substance control Question # two This is a 35 year old female who presents with right upper quadrant pain and nausea, vomiting due to acute cystitis. She undergoes a laparoscopic Eliza stuck to me with a JP drain. She has ongoing abdominal pain and her JP drain is now draining billions fluid E. R. C. P. Reveals this Kalinda graham. What is the next best step in management? A place of plastic stent to CBD be placed A cover metal stents of CBD. See surgical repair D. Called the surgeon for additional drain placement. The correct answer is C surgical repair. The colon diagram on the left shows a complete transaction of a bio duct. The contrast bills but they're still common bile duct but does not feel any of the proximal ducts above the surgical clips stenting into the common bile duct in this case will not resolve the violently coming from the proximal duct. There are four surgical intervention is recommended for partial transactions or short segment transactions. T tube drain placement and end to end anastomosis can be considered but this can be complicated by an S. Thematic structure in the future for a complete transactions and long segment transactions. Hypocritical judgment. Rostami is usually required. Question number three, A 70 year old men with history of hypertension presents with abdominal pain, jaundice and lethargy. He is very real 202°. Take a card with heart rate up 110 And hypotensive with blood pressure of 87/50. His white blood cell count is very high at 25 it's all of these are also elevated with total billy ribbon of 4.8 direct billy ribbon 3.6 A. S. T. A. L. T. 200. An Auckland Foster Taste. ultrasound of the abdomen shows gall stones in the gallbladder And common bile duct size is dilated at 12 mm. I. V. Fluids and I. V. Antibiotics were started in the er what is the next best step in management a continue antibiotics and observe B. E. R. C. P. See obtaining cT scan. D. Obtained M. R. C. P. E. Consult surgery for colon. Suspect to me the correct answer is B. E. R. C. P. This patient has a something cholangitis and Reynolds Penta characterized by hypertension, altered mental status, jaundice, fever and right upper quadrant pain cholangitis is caused by a biliary obstruction most commonly due to a gall stone in the common bile duct. This causes poor by a flow and increases political pressure, allowing translocation of bacteria across the biliary epithelium so stomach release of inflammatory cytokines bank cause sepsis and septic shock Cholangitis or Billy Ribbon. Higher than four are very strong predictors of Coca Cola Diocese. Therefore no further imaging is necessary and the RCP is recommended here are other predictors of ecological archdiocese according to the A. S. G. Guidelines. CBD is still demonstrated on the abdominal ultrasound. Clinical is something cholangitis. Billy Rubin higher than four are considered to be very strong predictors of political diocese. If you have any one of these three strong very strong predictors. The likelihood of political archdiocese is considered to be high Dilated. Common bile duct on ultrasound and Billy Ribbon between 1.824 are considered to be strong predictors of ecological at ISIS. If you have both of these strong predictors then the likelihood of political advices is considered to be high. Moderate predictors include abnormal all of these other than billy ribbon Age older than 55 and clinical gallstone pancreatitis. If you have none of these predictors, your likelihood of political advices are considered to be low and for all the other patients fall under intermedia category. If you're a likelihood of political advice is based on the predictors from prior slide is low. The recommendation is to proceed to laproscopic allies suspect to me if your likelihood of political advices as intermediate, the recommendation is to obtain further imaging or their P. M. R. C. P. U. S. Or IOC. During laparoscopy. If your likelihood of CBD stone is high based on your predictors then the recommendation is to proceed to E. R. C. P. There are multiple studies showing benefits of early ERCP To find us here to be performed within 24- 48 hours of presentation. In this one study from 2019 comparing early ErCP group to the late Air CP group for cholangitis. The early a recipe group was found to have lower in hospital mortality. Lower 30 The immortality, lower readmission rates, lower length of stay and lower hospitalization costs describe demonstrates rapidly increasing risk of mortality as the ERCP is delayed. Therefore early years CBS recommended and is the correct answer choice for this question. Question number four. The same 70 year old man with a sanding cholangitis from question number three under those urgent ERCP two stones are removed from the pistol. CBD fever results after ERCP blood pressure and heart rate stabilizes and local psychosis also improves. LFTs trended down gradually and is near normal. What is the next best step in management? A continue antibiotics and differ laproscopic Eliza step to me. Give an older age or B continue antibiotics and recommend laproscopic allies suspect to me. Mhm. The correct answer is B recommend polycystic kidney. A retrospective review of 11,000 patients during six year period showed a higher rates of recurrent complications in the RCP alone group compared to the E. R. C. P. Plus cola suspect army group lower weights of political advices cholangitis and gallstone pancreatitis were observed in ERCP plus colossus sect. Any group compared to the ERCP along group. This benefit was preserved in older patients and in patients with diagnosis of cancer. Chf liver disease and other comorbidities. There was no difference in post op complications such as rates of my DVT and PE. E. Question number five, 62 year old female with history of diabetes presents with worsening of right upper quadrant pain, nausea and fever for two days. She had similar pain on and off for a few months. She's a federal. Her vital signs are stable. White Blood Cell Count is 12. Total bilirubin three direct billy ribbon to point to A. S. T. 1 64 L. T. 300. Auckland fossil teas to 94 Or like pieces. 20 mm RCP shows the following image on the right. What is the best step in management? A surgery consultations for colon mastectomy? B. E. R. C. P. For colder Kohler diocese. See antibiotics and trend LFTs. D obtain a high to scan. The correct answer is a surgery consultation for cola suspect To me this patient has mercy syndrome. This condition is caused by and impact the gall stone in the gall bladder or cystic duct compressing onto the bile duct and causing a biliary obstruction. The M. R. C. P. Image on the left is showing a very large stone in the cystic duct as seen in the white arrow. And this is compressing onto the adjacent common bile duct, causing a biliary obstruction. And you can see d dilated and tripod duct bilaterally um at the location of the yellow arrows. Does this found in 2.7% of patients undergoing called mastectomy and sometimes can be very difficult to diagnose pre operatively. As the patients often present with exactly the same symptoms as political a diocese on the ERCP. The cool angiogram cannot identify the entire stone as the stone is located outside the bile duct. You'll often see a half filling defect or half moon shape from the extrinsic stone. There is an upstream biliary doctor. The rotation above the stone and any attempt to remove the stone by a bowline sleep will not be successful. As the stone is not within the bile duct, coaster stuck to me is recommended in severe cases with significant fibrosis. Laproscopic hysterectomy may not be possible and it's often converted to open close mastectomy or sub total colon mastectomy. In complex cases with fistula formation, A biliary enteric and esteem Asus may be required. Question number 6 44 year old men from Hong kong presents with right upper quadrant pain which is worse after eating and chills for three days. He has a similar symptoms intermittently in the past two years he's febrile has a stable blood pressure and his technique arctic with heart rate and the one teams, He is alert and oriented. Times three he appears jaundice and his tender in the right upper quadrant without any rebound or guarding. White blood cell count of 16 and elephants are elevated with total bilirubin of eight A. S. T 68 LT174 And Auckland Foster T. 600 mm. RCP shows the fuse intra and extra hepatic ductal dilatation. Numerous stones in the intra and extra hepatic ducts and then arrow had signed. What is the most likely diagnosis. A primary biliary sources. B primary sclerosing cholangitis. See recurrent cryogenic cholangitis or d viral hepatitis. The correct answer is c recurrent biogenic cholangitis. This was first described in 1930 by a British surgeon who worked many years in Hong Kong. Um initially this was coined in 1950s as the Hong Kong disease or Oriental cholangitis and is now known as the current biogenic cholangitis. Although the exact ideology is unknown, it's thought to be caused by parasitic infection causing biliary stasis, inflammatory changes involving obstruction. This is more prevalent in rural areas of Southeast asia than the west and it's characterized by innumerable pigmented stones throughout the intra and extra hepatic bile ducts. Patients present with bouts of acute cholangitis and over a long time can lead to structures and abscesses. Okay, diagnosis is made clinically by symptoms and the image lying on the left is an M. R. C. P. Image demonstrating a very dilated common bile duct and left right hypnotic dots. There are multiple building the effects due to heavy stone burden. There is a relative sparing of the distal branches of the intra paddock dots creating an appearance of an arrowhead sign. This is better seen on the kalandia graham on the right showing a severely dilated common bile duct and tapering off hypnotic ducks distantly E. R. C. P. Is recommended for complete stone clearance depending on stone burden and location. Multiple er cps would stand therapy and little trips. He may be necessary to achieve complete stone clearance. If the patient has recurrent cholangitis due to heavy stone burden and difficult to reach areas or due to frequent occurrence of stones partially protected. Me sometimes performed to remove the affected segments. Arsal is not usually effective and dissolving stones because stones are composed of calcium, billy Rubin, it instead of cholesterol by a lost his work by decreasing cholesterol synthesis and secretion and by increasing biliary bile acid concentration, thereby reducing cholesterol saturation index. Even for cholesterol stones. The current rate would also the optical asset is high, approximately 15% in one year and 45% recur in five years choice. A Pvcs incorrect although they do present what elevated Aquaman faucet taste and billy Ruben. Most patients with PVC are asymptomatic or have poor itis as their only presenting symptoms. 20% of them often have coexisting autoimmune disorders. PSC can present with cholangitis as well. However, they tend to have dominant structures or multi vocal structures in the biliary tree and this creates a classic beaded appearance. There is a strong association with IBD particularly you see and the mythology the keyword is onion skin appearance choice. The acute viral hepatitis incorrect because um viral hepatitis would not be presenting with chronic recurrent acute cholangitis over two years, it will also expect much higher levels of A. S. T. A. L. T. And viral hepatitis question number seven. A 50 year old woman presents with one year of interment, epic gastric pain and building. She denies fever, chills, nausea, vomiting anesthesia. Um Elena or weight loss. Cbc LFTs Emily's and like these are normal operandi asked the show's mild gastritis. Ultrasound of the abdomen shows non shadowing. Non hyper eco ick seven millimeter legion adherent to the gallbladder wall. There is no pericles, cystic fluid, gall bladder, wall, thickening or dilated bile ducts. What is the most likely diagnosis of the ultrasound? Finding? A. At noma B at no miyamoto sis see cholesterol Pollo de gaulle stone. The correct answer is C cholesterol polyps, Gallbladder polyp occurs in 5% of the population. Majority of these polyps are benign and of the benign polyps about 80 personal number cholesterol polyps Abnormal is only account for about 8% of gallbladder polyps and the other 8% are malignant polyps or legions. This is often incidentally detected on imaging when you obtain the imaging. For other indications. Unlike stone's polyps are not mobile and they do not create shadowing pere ultrasound images of gall stones and gall bladder polyps on the left will appreciate a large stone in the gall bladder creating a black shadowing artifact below the stone. Um The stone looks like a half moon shape and it's bright because because of its high precocity on the right is multiple. Um gallbladder polyps seen on ultrasound. Unlike the limiting on the left, it is not as bright and its adherent to the wall of the gall bladder and also not mobile. There is also lack of shadowing from these polyps, although the majority of Goldwater polyps are benign. There is an increased risk of malignancy in large Goldwater polyps. In this one retrospective study of 1000, 446 patients who underwent closest ectomy for gallbladder polyps, they looked at a number of factors that may increase risk of malignancy. Polyp size was the most important predictor of malignancy. 100 personal polyps larger than 20 were found to be malignant And 94% of Benign polyps are less than 10. Because of this guidelines recommend cool assist ectomy for Paul up size larger than 10. The exception to this rule is PSC PSC patients are at higher risk of developing Colombia carcinoma, calandra carcinoma developed an 11 personal patient with PSC. There are for colon mastectomies recommended for gallbladder polyp of any size. For PSC patients for gall bladder polyp size smaller than 10 millimeters surveillance ultrasound every six months is recommended. Does she be surveyed at least 1-2 years to demonstrate size. The ability If the polyp is rapidly enlarging or it becomes larger than 10 during the surveillance cola suspect. Um is recommended choice. A adenoma is incorrect at norma's have a similar appearance as gallbladder polyp an ultrasound but it is much less common than cholesterol, Pollo ethno Maria Matos, is can mimic the appearance of gallbladder polyp, especially when the wall thickening is vocal. However, the overgrowth of epithelium tends to be more diffused and this condition is also much less common than cholesterol. Apollo, although there is an unclear association of Colombia carcinoma, Most experts agree that cold mastectomy should be performed when the wall thickness that group in 10. Goldstone, as we previously discussed, appear hyper eco ick and can be mobile unlike a gall bladder polyp. Therefore, choice D. Is incorrect. Question number eight, which of the following factors increases the risk of developing black pigmented goldstone's a obesity. Be rapid weight loss. See sickle cell anemia. D. High vitamin C. Intake E. Estrogen replacement therapy, correct answer is C. Sickle cell anemia. All the other answer choices are associated with cholesterol stones, vitamin C. And take has shown to be a protective factor, not a risk factor. Sickle cell anemia is a hemolytic condition that increases concentration of billy ribbon and bile. Therefore, this condition is associated with pigmented stones rather than a cholesterol stone, gall stones can be made of cholesterol, billy ribbon calcium or a mixture of all of these cholesterol stones are the most common type of stones. They are more prevalent in Western countries and are associated with obesity. Female gender age and family history. Black pigmented stones are made of calcium, Billy Ruben eight. They are more common in asIA and more common in patients with cirrhosis, sickle cell disease or other hemolytic conditions. Brown pigmented stones are made of calcium. Soaps of fatty acids, cholesterol medicine, these are associated with infection and sepsis. There are many epidemiology studies and cohort studies looking at relationship between various factors and gall stones. These studies show that increasing age was associated with an increased prevalence of gall stones. Goldstone's are 4-10 times more frequent and older than younger subjects, biliary cholesterol saturation increases with age, the decline in the activity of cholesterol seven alpha hydroxy Alice, which is an rate limiting enzyme for bio acid synthesis. Women during their fertile ears are almost twice as likely as men to experience gall stones, estrogen increases cholesterol level in bile and also decreases gallbladder motility. Therefore promoting still information, 25% of morbidly obese individuals have Gallstone disease. Age adjusted risk ratio of six was found for gall stones and women with B. M. I greater than 32. Then there was a non obese control. Certain medications including estrogen, oral contraceptives, cefTRIAXone zone have been found to increase the risk of gall stones, decreased physical activity, especially in men and the lowest quantum of physical activity had increased risk ratio compared to those in the highest quantum of physical activity. The risk ratio was 1.72 for those in age 40- 64. Rapid weight loss can be a respective recall stones as well. When a person loses weight rapidly deliver excretes extra cholesterol and mobilizes cholesterol from adipose tissue storage in the fasting state called bladder contraction is reduced, causing biliary stasis, um promoting store information. The same studies have found the following factors to be protective against gall stones, calcium, vitamin C, coffee, physical exercise, high fiber diet, high vegetable protein, diet and statin. Use dietary calcium, decreases cholesterol saturation of gallbladder bile by preventing the reabsorption of secondary bile acids in the colon, calcium intake was inversely associated with call stone incidents in multi vari hazard analysis in animal studies, vitamin C increases cholesterol seven. Delphi trucks, Police activity in bile. This has an important role in metabolism of cholesterol to bile acids and start to decrease risk of the information cross section and novices of data from the second National Health and nutrition examination survey showed lower prevalence of gall stones and coal assist ectomy and those would hide serum levels of ascorbic acid. Coffee consumption seemed to be inversely correlated with stone prevalence as well. Do you do an increase and to entero hepatic circulation of bile acids? Coffee components, stimulate coalesces, still kind and release, enhances gallbladder motility and have a gall bladder flew with absorption and decreases cholesterol crystallization and bile. This concludes my presentation, then give her your attention and I wish you the best
