Biliary Disease

Overview

Abdominal Exam
- Murphy's sign
Labs
- Leukocytosis (left shift)
- Bilirubin
- Alk Phos
- ALT
- Amylase
  - Abnormal LFTs are not common in uncomplicated acute cholecystitis, as obstruction limited to gallbladder
Ultrasonography
- Sonographic Murphy's sign
- Gallbladder wall thickening >4mm or edema (double wall sign)
- Pericholecystic fluid
CT vs. MRCP if ultrasound unclear or if complications suspected

Surgery referral for symptomatic gallstones (biliary colic)
- Analgesia (NSAIDs, narcotic as second-line)
Expectant management for asymptomatic gallstones (only 10-20% will become symptomatic within 5-20y)
- Surgery may be considered in asymptomatic gallstones in the following situations:
  - Calcification of the gallbladder (porcelain gallbladder) because of high risk for gallbladder cancer
  - Hemolytic anemia (e.g., sickle cell disease)
  - Large gallstones (greater than 3 cm) because of high risk for gallbladder cancer
  - Morbidly obese undergoing bariatric surgery because of high risk to becoming symptomatic during rapid weight loss
  - Aboriginals because of high risk for gallbladder cancer
  - Planning for a transplant

Distinguish from biliary colic
- Lack of pain resolution, fever, peritonitis, abnormal labs
Types
- Calculous cholecystitis
- Acalculous cholecystitis - 10% (usually in critically ill patients)
Treatment
- No need for antibiotic prophylaxis in low risk
- Cholecystectomy
- Untreated, resolves within 7-10d but risk of complications (20% gallbladder gangrene, 2% perforation)

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