A 79 y.o. woman presents with nausea, vomiting and hypotension.

this is her abdominal CT What is wrong?

Our patient had a common duct stone resulting in severe cystic duct and bile duct dilation. So she had both choledocholithisasis and cholecystitis.

the stone is visible in the common duct

SPECTRUM OF BILIARY DISEASE

Biliary colic- contraction of the gallbladder  in the presence of an obstructed cystic duct.  The pain is acute and lasts 30 minutes to 6 hours. These patients should have a cholecystectomy at some point to prevent complications.

Acute cholecystitis-Cystic duct obstruction is accompanied by gall bladder inflammation and infection. If US is not helpful  a iminodiacetic acid scan where the gall bladder does not fill can be helpful. Antibiotics and cholecystectomy  are recommended with emergency surgery for perforation or emphysematous cholecystitis. ( usually casused by Clostridium perfringens)

thickening of the gallbladder wall with infiltration by neutrophils is present in acute cholecystitis-thinning and perforation of the wall are possible.

Acalculous cholecystitis –occurs in critically ill patients and results from gallbladder ischemia. Gall bladder wall thickening, pericholecystic fluid and pneumatosis without stones are the hallmark. This accounts for 10% of  all cases of cholecystitis.

an enlarged gallbladder without stones is present in acalculous cholecystitis. tension on the wall causes pain

Functional gall bladder disorder-Should be considered in patients without stones but with typical biliary colic pain. A gallbladder ejection fraction of less than 40% on cholecystokinin-stimulated cholescintigraphy supports the diagnosis.  Many of these patients do not improve with cholecystectomy.

Common duct stones and cholangitis-are a leading cause of obstructive jaundice and pancreatitis.  20% of common duct stones will pass on their own but most require removal. with  ERCP.  Cholangitis is infection of the biliary tree with Charcot’s triad: fever jaundice and RUQ pain.  Gram negative bacteria are odten the cause.  Antibiotics and removal of the obstruction are key.  MRCP can be performed if US imaging is not helpful.

Chronic infection of the gallbladder- Chronic infection is more common than acute infection. The gallbladder  is a reservoir for Salmonella typhi in chronically infected patients and puts them at risk for gallbladder cancer. Typhoid Mary was an example of someone with a chronically infected gallbladder. She was a cook who infected 122 people with typhoid fever.

typhoid mary was a cook who had an asymptomatic chronic Salmonella gallbladder infection

Autoimmune diseases of the biliary tree-Primary  biliary cholangitis affects small and medium bile ducts. Anitmitochondrial antibodies are diagnostic. It presents with elevated liver functions.  Primary sclerosing cholangitis is a disease of large bile ducts and is often associated with  inflammatory bowel disease. Antismooth muscle antibodies are often present.

Our patient failed endoscopic biliary cannulation due to previous Roux-en-Y gastrectomy and undersent percutaneous biliary drain placement. She grew E coli from the blood.

Rezkallah K, Barakat K, Farrah A, et al. Acute acalcuous cholecystitis due to primary acute Epstein-Barr virus infection treated with laparoscopic cholecystectomy: a case report Ann Med Surg (Lond) 2018Nov;35:189-191

Aledo V, Iniguez L, Funes D, et al. Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature. Fev Esp Enferm Dig. 2017Oct; 109(10):708-718.

ACP MKSAP 19 Gastroenterology and hepatology 2023 71-75