Moffitt GI Report – 1.10.18 – choledocholithiasis

Thank you to Kapil for presenting the case of an elderly male with a history of cholecystitis s/p cholecystectomy and ERCP with sphincterotomy for retained stones presenting with 3 days of nausea and generalized abdominal pain found to have recurrent choledocholithiasis. Thank you to our GI colleagues for their participation and teaching!

Key Pearls

  1. Murphy sign along with its sonographic variant is a useful (LR 2-3) and cost effective tool for diagnosis of acute cholecystitis. Be careful as this sign can be negative in elderly (more specific and less sensitive) or patients without a gallbladder!
  2. Patient’s with hx of cholecystectomy are at high risk for ascending cholangitis (obstruction of CBD) and should be empirically treated with antibiotics when presenting with recurrent abdominal.
  3. Acute cholecystitis – remember most common bugs are GNRs including E. Coli.
  4. Per Dr. Ostroff you are allowed to have ~ 1mm additional dilation of your CBD for every decade of life.

Evaluation of Jaundice

  1. Is the elevation of bilirubun real?
  2. Is the elevation Direct or indirect?
Direct Bilirubin Indirect Bilirubin
Obstruction (intra or posthepatic)

–          Stones

–          Strictures

o   Sclerosing cholangitis

–          Malignancy

o   Hepatocellular carcinoma

o   Cholangiocarcinoma

o   Pancreatic cancer

Hemolysis

–          Enzyme mediated

–          Membrane

–          Immune

–          Non-immune

Infectious

–          Hepatitis (viral)

–          Sepsis/Systemic Disease

Gilberts – unconjugated
Other

–          Alcoholic, NAFLD, ischemia, infiltration, TPN (long list)

Other

–          sepsis

Check out this evernote for more details and images regarding anatomy and causes of obstruction!

Murphy’s sign Test Characteristics

  1. A review of 17 studies found Murphy test to be useful positive LR: 2.8; 95% confidence interval (CI): 0.8 to 8.6 (Trowbridge RL, et al. 2003).
  2. Ralls and colleagues reviewed 497 patients of suspected acute cholecystitis and found that 98.8% of the patients in their series had a positive ultrasonographic Murphy sign. More, a combination of gallstones and a positive Murphy sign had a positive predictive value of 92.2% for acute cholecystitis, while the absence of gallstones together with a negative Murphy sign had a 95% negative predictive value.

 

 

 

 

 

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