Severe Cholecystitis Complications

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Questions and Answers

What is the percentage of high-risk symptomatic stones in the gallbladder?

30-40%

60-70%

10-12% (correct)

20-25%

What is the sensitivity of ultrasound in diagnosing CBD stones?

94%

86%

73% (correct)

80%

What is the characteristic of Ascaritic Biliary Pain?

Pain associated with food intake

Pain localized over the epigastric/RUQ (correct)

Pain relieved by analgesics/opiates

Pain worsens with change in body position

What is the specificity of ultrasound in diagnosing CBD stones?

91% Signup and view all the answers

What is the definite diagnosis of a patient based on the Tokyo Guidelines 2018?

One item in A, one item in B, and one item in C Signup and view all the answers

What is the diagnostic accuracy of MRCP in diagnosing obstructive jaundice?

98% Signup and view all the answers

What is the hallmark of Charcot's Triad?

Jaundice, fever, and abdominal pain Signup and view all the answers

What is the management approach for Type II choledochal cysts?

Excision Signup and view all the answers

What is the characteristic appearance of primary sclerosing cholangitis on imaging tests?

Multifocal, short annular strictures alternating with normal or dilated segments Signup and view all the answers

What is the percentage of patients with primary sclerosing cholangitis who have a coexisting inflammatory disorder?

50% Signup and view all the answers

What is the most common type of choledochal cyst based on the Todani classification?

Type I Signup and view all the answers

What is the cancer risk associated with Type II and III choledochal cysts?

Lowest risk Signup and view all the answers

What percentage of cholesterol comes from endogenous sources?

60% Signup and view all the answers

What is the rate-limiting enzyme in cholesterol synthesis?

HMG-CoA Reductase Signup and view all the answers

What is the primary function of bile acids in the digestive system?

Emulsification of fats Signup and view all the answers

What is the term for the process by which bacteria in the colon convert primary bile acids into secondary bile acids?

Dehydroxylation Signup and view all the answers

What is the most common type of gallstone?

Cholesterol stone Signup and view all the answers

What is a risk factor for symptoms of gallstones?

Female gender Signup and view all the answers

What is the recommended surgical approach for gallbladder polyps ≥10 to 20 mm?

Laparoscopic cholecystectomy with full thickness dissection Signup and view all the answers

What is the recommended management for patients with primary sclerosing cholangitis with gallbladder polyps >8 mm?

Cholecystectomy is indicated Signup and view all the answers

What is the recommended surgical approach for gallbladder polyps >20 mm?

Extended cholecystectomy with lymph node dissection and partial hepatic resection Signup and view all the answers

What should prompt referral to a surgeon for cholecystectomy?

An increase in size of >2 mm on imaging Signup and view all the answers

What is the recommended management for patients who are unable or unwilling to undergo cholecystectomy?

Surveillance ultrasound at 6 months and then annually Signup and view all the answers

What is the primary benefit of using MRCP in the diagnosis of cholangiocarcinoma?

Assessment of the extent of bile duct invasion Signup and view all the answers

In patients with suspected distal cholangiocarcinoma, what is the preferred diagnostic modality?

ERCP with brush cytology Signup and view all the answers

What is the primary indication for stent placement in patients with cholangiocarcinoma?

Bilirubin >10 mg/dL Signup and view all the answers

What is the 5-year survival rate for patients with cholangiocarcinoma?

5-10% Signup and view all the answers

In patients with an isolated intrahepatic mass on imaging and a normal serum level of AFP, what should be considered?

Cholangiocarcinoma Signup and view all the answers

What is the resectability criterion for cholangiocarcinoma?

All of the above Signup and view all the answers

Study Notes

Imaging and Diagnosis

Imaging evidence critical for etiology determination (e.g., stricture, stone, stent).
Suspected diagnoses require one element from category A plus one from B or C.
Definite diagnoses necessitate one item from all three categories: A, B, and C.

Severity Grading and Initial Management (Tokyo Guidelines 2018)

Organ dysfunction onset leads to ICU resuscitation.
Cardiovascular: Requires broad-spectrum antibiotics; use dopamine (25 µg/kg/min) or norepinephrine stabilization for biliary drainage.
Neurologic: Consciousness disturbance indicates severity.
Respiratory: P/F ratio less than 2.0 mg/dL suggests respiratory compromise.
Hepatic: PT-INR greater than 1.5 denotes liver dysfunction.
Hematologic: Thrombocytopenia with platelet count below 12,000/mm³ indicates severe issues.

Imaging Tests and Findings

Ultrasound and CT scans confirm diagnoses; cystic duct dilatation can indicate malignancy.
ERCP and MRCP are essential for biliary anatomy assessment and surgical management planning.
Type I (Fusiform dilation) is the most common type of cholangiopathy (60-85% of cases).
Multiple extrahepatic cysts are typical in Type IVB classifications, while Type III is rarely seen (1-5%).

Chronic Conditions and Classifications

Todani classification categorizes abnormalities in biliary anatomy.
Primary sclerosing cholangitis (PSC) seen in 41% of cases could be associated with other inflammatory disorders (76% ulcerative colitis).
Imaging often reveals “beaded appearance” with multifocal, short annular strictures interspersed with normal/dilated segments.

Clinical Manifestations

Around 50% of cases are asymptomatic.
Common symptoms include biliary pain, jaundice, cholangitis (notable: Charcot’s triad and Reynolds pentad).
Biliary ascariasis results in sudden, non-food-related epigastric pain.

Diagnosis and Sensitivity of Imaging Tests

Ultrasound has 73% sensitivity and 91% specificity for diagnosing biliary issues but poor for distal CBD stones.
Non-invasive MRCP provides comprehensive views, important for preoperative assessments, and has 98% diagnostic accuracy for obstructive jaundice.
Endoscopic ultrasound offers higher sensitivity in diagnosing malignancies compared to brush cytology.

Distal Cholangiocarcinoma Investigation

Suspected cases warrant ERCP for visualization and cytology.
Risks include ascending cholangitis and challenges in determining tumor extent.

Prognosis and Resectability

Distal cholangiocarcinoma shows the highest resectability rates; intrahepatic a much lower.
Criteria for resectability include absence of metastasis or invasion of adjacent organs.

Cholesterol Synthesis and Bile Acids

60% of cholesterol originates endogenously, synthesized primarily by HMG-CoA reductase.
Primary bile acids include cholic and chenodeoxycholic acids; secondary bile acids occur post-bacterial modification.
Gender, stone size, and mobility significantly influence the risk and symptomatology of gallstone disease.

Management of Gallbladder Polyps

Polyps ≥10-20 mm need laparoscopic cholecystectomy; those >20 mm may necessitate extended cholecystectomy with lymph node dissection.
Close monitoring indicated for polyps >8 mm in patients with PSC; size changes prompt surgical review.

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Description

This quiz assesses knowledge on severe complications of cholecystitis, including local inflammation and organ dysfunction. It covers topics such as gangrenous cholecystitis, pericholecystic abscess, and circulatory failure.