#Choledocholithiasis

Ddx: PUD, acute pancreatitis, IBS, acute hepatitis, acute pyelonephritis, STEMI, PNA right sided, sickle cell disease acute crisis, Herpes Zoster

-History of gallstones?

-History of gallbladder surgery?

-Post-liver transplant?

-Symptoms: asymptomatic, biliary colic, obstructive jaundice (itching, dark urine, acholic stools), nausea/vomiting, RUQ pain after eating, epigastric pain

-Pre-test probability: visualization of a common bile duct stone on abdominal ultrasound (73% sensitivity and 91% specificity), clinical evidence of acute cholangitis, a bilirubin greater than 1.7 mg/dL and a dilated CBD (the presence of two or more of these factors has a pre-test probability of 50%-94% for choledocholithiasis)

-Physical exam: jaundice, RUQ pain, epigastric tenderness

-evaluate for signs of cholecystitis (pain occurring after food at night, murphy sign or RUQ mass/pain/tenderness + fevers, WBC count, CRP + US findings of enlarged gallbladder, gallbladder wall thickening, gallbladder stones, debris echo, dilated common bile duct, pericholecystic cystic fluid)

-evaluate for signs of cholangitis (abdominal pain, jaundice, fever, confusion, hypotension)

-evaluate for pancreatitis (lipase)

-AST/ALT (if elevated, ask alcohol, hepatitis)

-RUQUS (include visualization of a common bile duct stone and a dilated common bile duct greater than 8-mm)

-EUS (sensitivity and specificity is approximately 95 and 97%)

-MRCP (noninvasive, sensitivity of > 90% and specificity nearing 100%)

Plan:

-f/up CBC to assess WBC count

-f/up CMP/liver enzymes/T. Bilirubin/Alk. Phos (PPV low of positive liver enzymes, but NPV high. Expect primarily cholestatic pattern (disproportionate elevation of the alkaline phosphatase, gamma-glutamyl transferase, and bilirubin)

-send GGT

-f/up RUQUS (dilated CBD on transabdominal ultrasound is suggestive of, but not specific for, choledocholithiasis)

-send blood cultures

-f/up lipase

-/fup lactate

-NPO

-IV fluids

-pain control with ***

-monitor closely for signs/symptoms of cholangitis (fever, rising WBC count, hypotension, sepsis) and pancreatitis

***cholecystitis vs. Choledocholithiasis--acute cholecystitis should not have significantly elevated bilirubin or Alk Phos unless secondary process is causing cholestasis. Abdominal imaging on cholecystitis usually has normal CBD, gallbladder wall thickening, and a sonographic Murphy's sign

***if cholecystitis--plan for cholecystectomy inpatient, within 72-hours for mild cholecystitis

***Mild/moderate cholecystitis--Ceftriaxone, Cefuroxime, Cefazolin

***Severe/Healthcare Associated--Flagyl + Ciprofloxacin, Ceftazidime, Cefepime OR monotherapy with Zosyn vs. Meropenem. If healthcare-associated then add Vancomycin

***-if febrile, blood cx

Risks per Guidelines:

>High risk if

1. Common bile duct stone on US or cross-sectional

Imaging

2. Total bilirubin >4 mg/dL and dilated common bile duct

3. Ascending cholangitis

>Intermediate risk: 1. abnormal liver tests 2. age >55 years 3. dilated CBD on ultrasound, (we suggest EUS, MRCP (not the best for stones <5mm), laparoscopic intraoperative

cholangiography (IOC), or laparoscopic intraoperative ultrasound for further evaluation)

For patients with symptomatic cholelithiasis without any of these risk factors, we

suggest cholecystecomy without IOC.

3 factors that increase duct size:

Age, opioids, and prior cholecystectomy

Double duct sign (both pancreatic/biliary ducts enlarged):

Ampullary mass

Pancreatic mass/cyst

Cholangiocarcinoma

Papillary stenosis, including from long-term opioid use

Choledochal cyst

#Choledocolithiasis plan:

-NPO @ ***MN for ERCP tomorrow

-monitor CMP (liver enzymes) and CBC daily

***-OK to continue antibiotic therapy

***-send/follow-up blood cultures

-close monitoring for signs/symptoms of cholangitis

***anticoagulation?

-Active Type & Screen

-Platelet >50k, PTT<50

-correct coagulopathy for goal INR <1.5

-Hold DVT Ppx night of/day of procedure