Post cholecystectomy jaundice
Work-up and algorithm
H&P - look for peritonitis
Labs - esp LFTs and amylase
Abdominal films
Start abx
U/S RUQ - bil dil, stones, biloma, abscess
HIDA
If CBD occluded, get ERCP. If ERCP shows stone, retrieve. If can't ERCP or shows iatrogenic occlusion, explore.
May repair over T-tube, remove clip, choledocho-jej
IF HIDA shows leak, get CT scan
Drain the biloma, if it's the cystic duct, should close in 1-2 wks. If CBD, get ERCP, stent. Wait 3 weeks (for things to cool down), then OR - repair over T-tube or choldocho-jej (if tissue unhealthy or a lot of tension)
If HIDA shows normal - CT scan. IF CT also normal, look for other causes of jaundice.
Post cholecystectomy cholangitis
Here, the patient is septic, and you need to drain the biliary tree.
Algorithm
ABCs, access, H&P.
Labs, plain films, abx.
Emergent ERCP to drain the CBD. Can remove stone, bx mass.
If that's a no go, PTCD.
If that's a no go, resuscitate patient and go to OR, with the goal of draining the biliary tree.
Explore CBD, extract stone (may use choledochoscope)
If having trouble, or unstabe, put a T-tube in CBD and close.
If patient is stable and you want to drain internally, do a choledochoduodenostomy if porta not too scarred (can leave stone). If porta is scarred, and duo won't mobilize, do sphincterotomy. If still can't get stone, do choledocho-jej.
Post-cholecystectomy syndrome
"Still has pain s/p CCY"
ddx:
GERD, PUD, pancreatitis, IBS
Biliary: CBD stone/stricture, SOD, biliary dyskinesia
Workup
H&P - characterize pain
Labs - including LFTs, amylase/lipase
Tests:
EGD/ERCP
CT if you suspect pancreas
RUQ U/S - CBD >12mm is abnormal
HIDA delayed emptying >2h c/w biliary dyskinesia (remember, there is no gallbladder, so no EF)
Treatment - direct to etiology
Pt may benefit fropm sphincterotomy (ERCP or surgical TDS) if:
HIDA emptying >2h
CBD >12mm
Good wendoscopist can't cannulate ampulla
Pain reproduced by injecting CBD
Choledochal cyst
Types
I - most common - involves CBD
Complications
Malignancy
Treatment
Excision and hepatico-jej
If the dissection is tough, you can enter the cyst and develop a subserosal or submucosal plane, leaving the outside intact.
Also do CCY
Primary sclerosing cholangitis
Associated with IBD, can be idiopathic
Diffuse or localized extrahepatic stenoses
Recurring cholangitis/jaundice
Pts die 2/2 cirrhosis
Treatment
IR stents (can be changed q3 months)
Surgical hepatico-jej or choldocho-jej (place stents pre-op for identification)
Liver transplant
Acalculous cholecystitis
Risk - TPN - biliary stasis
Diagnosis
Portable RUQ US (not HIDA - gotta move pt and could be false neg in acalculous cholecystitis)
Elevated SGPT raises suspicion
Treatment
If sick, percutaneous cholecystomsomy under US guidance by IR
If no IR, do minilaparotomy and open cholestostomy under local
Less sick types with biliary dyskinesia
HIDA with CCK: if GB EF <30%, elective CCY
Biliary cancer
Gallbladder cancer
Stage I Mucosa
Stage II infiltrates subserosal layer, but serosa is uninvolved
Stage III thru serosa (into liver), or lymph nodes I, but <2cm
Stage IV, thru serosa (into liver), or lymph nodes +, but >2cm
Treatment
If I/II - CCY
III/IV - radical CCY - resect 2 cm of liver bed, dissect porta and anterior/inferior panc nodes
Distant mets - no surgery
If you are gonna go back to radicalize the CCY, do mets w/u 1st!
Bile duct cancer
Proximal (Klatskin) - at bifurcation
Middle third - CBD, not intrapancreatic
Distal - intrapancreatic
Work-up
1. r/o other causes of obstructive jaundice (stones, extrinsic compression of CBD by nodes from other cancer, sclerosisng cholangitis)
2. r/o mets
CT abd/chest
ERCP/PTC (can also get bx or brushings)
(Angio)
MR/MRCP
Treatment
Can start with laporoscopy
Look at nodes, liver, surfaces, hepatic plate
If looks unresectable, think drainage - ERCP/PTC, hepatico-jej)
Distal - Whipple
Middle - CCY, resect CBD up to pancreas, hepatico-jej
Proximal - CCY, dissect out porta, may include caudate lobe if involved, hepatico-jej
Post-op - adjuvant XRT, 5-FU
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