Biliary Problems: Stones and Sludge

Lecture Notes

When a patient presents with a cc of ruq abdominal pain the first thing you will do. Like we do with all other chief complaints is create a list of critical differential diagnosis.

Critical Differential Diagnosis:

  • Symptomatic cholelithiasis

  • Acute cholecystitis

  • Choledocholithiasis

  • Gallstone pancreatitis

  • Cholangitis

  • Pancreatitis

  • (insert all ddx for abdominal pain including appendicitis)

  • Consider retroperitoneal structures (i.e. AAA or pancreatitis).

In this lecture we will focus on the biliary system.

When you look at the RUQ US the questions you want to ask yourself is if there is

  1. Gallstones

  2. Gallbladder Wall Thickness (Gallbladder anterior wall <3 mm)

  3. Biliary Sludge

  4. Pericholecystic fluid

  5. CBD Dilation (nml: Common bile duct < 6 mm plus 1mm per decade after 60 yrs old)

  6. Sonographic Murphy’s sign

Symptomatic Cholelithiasis

  • Ultrasound will reveal gallstones without any signs of inflammation and no dilation of the CBD.

  • Treatment: Pain management followed by outpatient surgical evaluation.

Acute Cholecystitis:

  • Ultrasound:

    • +Gallstones

    • +Gallbladder wall thickening

    • +Biliar Sludge

    • +Pericholecystic fluid

    • +Sonographic Murphys

  • Treatment:

    • Antibiotics: Cover gram negatives (i.e. Ceftriaxone) and Anaerobes (i.e. Flagyl)

    • Emergent surgical consult with admission

Choledocholithiasis

  • Ultrasound:

    • +Gallstones

    • +Dilated CBD

  • Labs:

    • Elevated LFTS

  • Treatment:

    • Needs ERCP. Consult whoever does that at your facility GI vs surgery

    • No need for abx unless pt is having fevers or other signs of infection

Summary: Dilated CBD + LFTs = Choledocholithiasis.

Gallstone Pancreatitis

  • Ultrasound:

    • +Gallstones

  • Labs:

    • Elevated Lipase

  • Treatment:

    • Needs ERCP. Consult whoever does that at your facility GI vs surgery

    • No need for abx unless pt is having fevers or other signs of infection

Cholangitis

  • Charcots Triad:

    • Fever

    • Jaundice

    • RUQ Pain

  • Reynold’s Pentad:

    • Charcots Triad + altered mental status + hypotension

  • Treatment:

    • Aggressive sepsis management with ivf and pressors

    • IV ABX

    • Consult

      • GI for emergent ERCP

      • Surgery for cholecystectomy

      • IR for possible percutaneous drain

DDXof.com Algorithm For Hepatobiliary Ultrasound

Full ddxof.com article and algorithm on Hepatobiliary Ultrasound can be found at https://ddxof.com/hepatobiliary-ultrasound/

Full ddxof.com article and algorithm on Hepatobiliary Ultrasound can be found at https://ddxof.com/hepatobiliary-ultrasound/


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