Gallbladder and Cholelithiasis

Gallbladder and Cholelithiasis (Stones)

• Gallbladder disease is 90% attributed to stones.
• Cholesterol stones make up 80-90% of gallstones.
• Pigmented stones account for 10-20% of gallstones.
• 60-80% of individuals with gallstones are asymptomatic.
• 10-15% of all adults have gallstones.
• Predisposing factors for gallstones: Female, fat, fair, forty, fertile, contraceptive steroids, family history, gastroplasty, parenteral nutrition/fasting, and Crohn's disease.

Gallbladder Disease

• Often follows a fatty meal.
• Symptomatic at night.
• Presents as RUQ pain radiating to the right shoulder.
• The pain is steady, not colicky.
• Jaundice occurs in 15% of cases.
• A palpable mass in the RUQ is present in 30-40% of cases with cholecystitis.
• Inspiratory arrest with palpation and inhalation indicates Murphy's sign.

Biliary Colic

• Caused by obstruction.
• Characterized by epigastric visceral-type, steady pain.
• Has a sudden onset lasting 1-3 hours.
• Complications include recurrence in 50% of cases.
• No fever or leukocytosis.
• Normal lab results.
• The mechanism involves functional spasm of the cystic duct due to stones.
• Symptoms include gas, bloating, and heartburn.

Acute Cholecystitis

• Results from bacterial infection.
• Pain is described as RUQ (local) parietal type with a possible palpable mass and a positive Murphy's sign.
• Duration is more than 3 hours but less than 72 hours.
• Complications occur in 25% of cases.
• Fever is present.
• Leukocytosis is present.
• Increased WBCs (neutrophils), AST/ALT, hyperbilirubinemia, alkaline phosphatase, and serum amylase (if pancreatic duct obstruction).
• Symptoms occur at night hours after a fatty meal, including bloating, gas, and heartburn.
• Often preceded by attacks of biliary colic.

Imaging and Testing for Gallbladder Issues

• Ultrasound is the gold standard for visualizing the ductal system and spotting stones.
• ERCP involves inserting a scope into the sphincter of Oddi and injecting dye to view the biliary tree on X-ray, and the procedure is uncommon.
• Hepatobiliary Scintigraphy uses a trace isotope to visualize the biliary tree. Requires a 24-hour fast and technetium-99m injection, imaged under a gamma camera.
• Treatment involves laparoscopic removal or open cholecystectomy.

Alternative Care for Gallbladder Issues

• Identify and avoid possible food allergies and restrict sugar intake.
• Fiber helps
• Common allergy triggers include eggs and beef.
• Consider lecithin and omega-3 supplements
• Lipotropic factors decrease fat deposits on the liver, supporting liver cell membranes and fat transport, benefiting those with alcoholism, obesity, or malnutrition.
• Examples of lipotropic factors: Choline, methionine, inositol, folic acid, and B12.
• Choleretics/cholagogues promote bile secretion: dandelion stimulates bile flow and gallbladder contractions, and turmeric/artichoke leaves.
• Liver support includes silymarin, dandelion, and turmeric, where milk thistle alters the liver's outer membrane and blocks toxins from entering.
• An olive oil flush may help dislodge stones in the biliary tree

Post Cholecystectomy Syndrome (Biliary Dyskinesia)

• Sphincter of Oddi dysfunction
• Symptoms: upset stomach, nausea, vomiting, gas, bloating, diarrhea, and persistent RUQ pain.
• Differential diagnosis includes considering occasional jaundice.

Acute Pancreatitis

• Most common causes include alcohol and gallstones.
• Other causes: trauma, high triglycerides, drugs, heredity, and idiopathic factors.
• Signs and symptoms include severe epigastric pain that is constant, dull, and boring, radiating to the flank/back. The pain worsens in the supine position and is best when bent over/seated/fetal.
• Nausea and vomiting occur in 75-90% of cases.
• Aggravated by meals.
• The physical exam may reveal tenderness and abdominal distension.
• Bleeding indicated by Cullen's sign (periumbilical) or Turner's sign (flank).
• Jaundice possible.

Acute Pancreatitis: Labs and Imaging

• Lab findings: elevated WBCs (PMNs), normal RBCs, CMP indicates liver AST/ALT.
• Low calcium, hyperbilirubinemia (88-100%), elevated triglycerides and alkaline phosphatase (78%), GGT, amylase (2-5 days), and lipase (more specific) with a limited time frame.
• Colon cut-off sign on X-ray indicates the cutoff of the colonic gas column at the splenic flexure.
• Ultrasounds are useful for detecting gallstones.
• CT scan is the gold standard
• ERCP has limited value
• Management includes NPO and pain control.

Chronic Pancreatitis

• Most common cause is alcohol (70%).
• Idiopathic in 25% of cases
• Other causes include ductal obstruction (gallstones), heredity, hyperlipidemia, and cystic fibrosis.
• Signs and symptoms include mid-abdominal pain that is initially isolated but becomes continuous with flare-ups, may radiate to the back, and may be relieved by bending forward, often worse 15-30 minutes after a meal and may worsen with alcohol consumption. Nausea, vomiting, weight loss, diarrhea.
• Pancreatic insufficiency leads to malabsorption, pain, and diabetes.
• Steatorrhea and fat-soluble vitamin deficiencies.
• Glucose intolerance.

Chronic Pancreatitis: Labs, Imaging and Management

• Lab findings include mild AST/ALT, glucose abnormalities, glucosuria, elevated lipase (normal amylase), and steatorrhea.
• X-ray may show calcifications in the epigastric area (30-50% of patients) and CT is the gold standard for imaging.
• Management includes avoiding alcohol, pain relief, smaller meals, low-fat diet, MCT supplements, digestive aids, and support for glucose intolerance and malabsorption.

Zollinger-Ellison Syndrome

• Rare, benign tumor, usually located in the pancreas and duodenum, that secretes gastrin, stimulating parietal cells resulting in increased stomach acid (HCl).
• Symptoms and signs include diarrhea, abdominal pain, bleeding, and yellow fat in stool.
• Therapy includes medication to reduce acid production, removal of tumors if possible, and removal of parietal cells, it may be a cause of recurrent DUD symptoms.

Pancreatic Cancer

• Usually in the head of the pancreas
• Creates painless distension (palpable) of the gallbladder (Courvoisier's Law).
• Risk factors include age, smoking, charred meat, diabetes, family history, and H. pylori infection.
• No screening for pancreatic cancer
• Signs and symptoms include abdominal pain, anorexia, weight loss, painless jaundice (obstructed ducts), and are often absent.
• Imaging includes CT
• Prognosis includes a 5-year survival rate of 5% and a median survival of 3-6 months.

Hepatitis A (Acute)

• Virus found in feces of infected persons.
• Spread by close personal contact (sex or sharing household)
• Transmitted via the anal-oral route through contaminated food, drinks, or shellfish (partially cooked).
• Normally an acute form and almost never becomes chronic
• Acute: all symptoms, signs, and CMP findings resolve within 12 months
• Chronic: persists longer than 12 months with minimal liver damage compared to Hepatitis B/C
• Diagnosed by detecting HAV-specific IgM antibodies in the blood detectable 1-2 weeks after infection and persists up to 14 weeks; the presence of IgG antibodies indicates prior infection and immunity.
• AST/ALT are elevated during acute infection: IgM is an early marker; IgG is a late marker.

Hepatitis B

• HBV is found in blood and certain body fluids
• Spread by unprotected sex, sharing needles, needle sticks/sharps exposures, or infected mothers during childbirth.
• Exposure to infected blood in any situation
• Can present as an acute or chronic form
• A vaccine is available

Hepatitis C (chronic)

• Transmission via blood and certain body fluids, needle/sharps exposure, and infected mothers during birth.
• Not common during sex
• Incubation period: 14-180 days (average 45 days)
• Chronic condition: longer than 12 months

Hepatitis D

• Requires a current HBV infection to get HDV.
• Hepatitis D lives in the shell of HepB, thus requiring HBsAg.
• Transmission via sharing needles, unprotected sex with an infected person, and childbirth from an infected mother.

Hepatitis: Signs and Symptoms

• Anorexia (90%)
• Malaise (95%)
• Nausea & Vomiting (80%)
• Abdominal pain, diarrhea, weight loss, arthralgias (less common), and loss of taste.
• Overall has symptoms similar to the flu
• Fever, dark urine, jaundice (look at the eyes if not on the skin)
• Hepatomegaly and splenomegaly
• Clinical course has four phases: incubation, pre-icteric (prodrome), icteric, and convalescent

1. Incubation: Virus is replicating
2. Pre-Icteric: (Prodrome) Symptoms starting to develop. AST/AST elevating
3. Icteric phase: Bilirubin levels up enough to cause jaundice, dark urine
4. Convalescent: Feeling better and lab result returning to normal. Antibody markers are present.

• IF things do not resolve in 12 months = Chronic Viral Hepatitis

Hepatitis: Labs

• Liver cell necrosis indicated
  • AST elevated x10
  • ALT elevated x10
• ALK Phos – mildly elevated
• Hyperbilirubinemia-
• Albumin increased (Acute liver disease)
• Urine: Urobilinogen increased and Bilirubin: elevated in late hepatitis
• Mild leukopenia with or without relative lymphocytosis
• Acute Viral Hepatitis is not the only thing to cause significant elevation of AST/ALT But is sure one of possible causes to consider

Hepatitis: Serological Markers (Abs and Ags) and Acute Hep A

• Hepatitis Panel II: Acute •
• Hepatitis B Surface Antigen (HBsAg) •
• Hepatitis B Core IgM Antibody •
• Hepatitis A Antibody (HAVAB) (Total and IgM) •
• Hepatitis C Virus Antibody
• Acute Hep A
  • Incubation
  • Symptoms -AST/ALT • Green line
  • Serologic markers •
  • 1. IgM anti-HAV(IgG) • Broken red line

2. IgG anti -HAV • Blue line • Past infection: Gives lasting immunity

• IgM - recent infection
• IgG - past infection = immunity

Hep B and Hep C

• Hep B HBs Ag (surface Ag) • Outer shell of virus • Current infection • Carrier state (red)

• Anti-HBs - red • Resolved, not carrier

• Anti-HBc (Ab to core Ag) - green line • Resolved, not carrier

• If you have any of these markers = Hep B

• Hep C

• Anti-HCV - Ab to Hep C

Liver and Biliary Track Disorders

• Cirrhosis
  • Alcohol
  • Viral Hep (B,C,D)
  • Uncommon causes
    • Wilson's disease
    • Hemochromatosis
    • Alpha 1-antitrypsin def. S/S
• Ascites & Edema
• Fatigue Nausea
• Anorexia / Weight Change
• Jaundice / Pruritus(itchiness) Alcoholic Cirrhosis
• Palmar Erythema (Stigmata of Liver Disease)
• Spider Angiomas
• Parotid enlargement
• Testicular atrophy
• Impotence
• Gynecomastia
• Dupuytren's contracture - contraction of digits 4/5
• Loss of Body Hair Esophageal Varices d/t portal hypertension
• Vomiting Blood (Mallory -Weiss syndrome)
• Menstrual abnormalities
• Insulin Resistance / Prolonged bleeding time
• Liver Coma (nitrogenous wastes toxic to CNS)
• LIVER DOES A LOT. SO WITH CIRRHOSIS A LOT GOES BAD

Physical Exam

• Mild hepatomegaly - Gradual enlargement
• Splenomegaly
• RUQ mild tenderness
• Ascites d/t portal HTN
• Puddles sign - fluid around umbilicus. Creates resonance on percussion
• Shifting dullness sign
• Fluid wave sign - slap flank on one side, feel wave on other

Lab and Medications/herbs that may affect liver

• AST/ALT x1-4
• Ultrasound
• Biopsy
• If ^GGT = biliary tree stasis or chronic alcohol abuse
• Medications/herbs that may affect liver
  • Acetaminophen
  • Naproxen
  • Estrogens
  • Statin drugs
  • Vitamin A & Niacin (high amounts)

MGMT

• Reduce alcohol consumption
• Restrict salt and diuretics
• Decrease protein intake
• Liver transplant
• Glutathione**** - milk thistle increases glutathione as well
• Lipotropic factors(methionine, choline, inositol) - metabolizes fat in liver
• Cruciferous vegetables

Hereditary Hemochromatosis

• abnormal iron absorption
• Relatively common 1-300 people
• M>F 40-60s
• Organs affected - Liver #1
  • Heart, pancreas, joints
• S/S
  • Cirrhosis
• Cardiac problems
• Fatigue, pain, arthralgia
• DX: -Iron testing
  • Liver biopsy
  • Genetic testing (C282Y gene) FYI
  • Hereditary Prognosis better when DXed soon before significant liver damage Wilson's Disease

Wilson's Disease, Alpha-1 Antitrypsin Deficiency, and Primary Biliary Cholangitis

• Wilson's Disease
• lenticular degeneration & hepatic cirrhosis
• Genetic defect: copper is released into the system, and accumulates -Brain • Liver • kidney • Cornea • heart • pancreas.
• Rarely before age