ERCP

ERCP stands for endoscopic retrograde cholangiopancreatography. As hard as this is to say, the actual exam is fairly simple. A dye is injected into the bile and pancreatic ducts using a flexible, video endoscope. Then x-rays are taken to outline the bile ducts and pancreas. The liver produces bile, which flows through the ducts, passes or fills the gallbladder and then enters the intestine (duodenum) just beyond the stomach. The pancreas, which is six to eight inches long, sits behind the stomach. This organ secretes digestive enzymes that flow into the intestine through the same opening as the bile. Both bile and enzymes are needed to digest food. Equipment The flexible endoscope is a remarkable piece of equipment that can be directed and moved around the many bends in the upper gastrointestinal tract. The newer video endoscopes have a tiny, optically sensitive computer chip at the end. Electronic signals are then transmitted up the scope to the computer which then displays the image on a large video screen. An open channel in the scope allows other instruments to be passed through it to perform biopsies, inject solutions, or place stents. Reasons for the Exam Due to factors related to diet, environment and heredity, the bile ducts, gallbladder and pancreas are the seat of numerous disorders. These can develop into a variety of diseases and/or symptoms. ERCP helps in diagnosing and often in treating the condition. ERCP is used for:

Gallstones, which are trapped in the main bile duct Blockage of the bile duct Yellow jaundice, which turns the skin yellow and the urine dark Undiagnosed upper-abdominal pain Cancer of the bile ducts or pancreas Pancreatitis (inflammation of the pancreas)

Preparation The only preparation needed before an ERCP is to not eat or drink for eight hours prior to the procedure. You may be asked to stop certain medications such as aspirin before the procedure. Check with the physician. The Procedure An ERCP uses x-ray films and is performed in an x-ray room. The throat is anesthetized with a spray or solution, and the patient is usually mildly sedated. The endoscope is then gently inserted into the upper esophagus. The patient breathes easily throughout the exam, with gagging rarely occurring. A thin tube is inserted through the endoscope to the main bile duct entering the duodenum. Dye is then injected into this bile duct and/or the pancreatic duct and x-ray films are taken. The patient lies on his or her left side and then turns onto the stomach to allow complete

visualization of the ducts. If a gallstone is found, steps may be taken to remove it. If the duct has become narrowed, an incision can be made using electrocautery (electrical heat) to relieve the blockage. Additionally, it is possible to widen narrowed ducts and to place small tubing, called stents, in these areas to keep them open. The exam takes from 20 to 40 minutes, after which the patient is taken to the recovery area. Results After the exam, the physician explains the results. If the effects of the sedatives are prolonged, the physician may suggest an appointment for a later date when the patient can fully understand the results. Benefits An ERCP is performed primarily to identify and/or correct a problem in the bile ducts or pancreas. This means the test enables a diagnosis to be made upon which specific treatment can be given. If a gallstone is found during the exam, it can often be removed, eliminating the need for major surgery. If a blockage in the bile duct causes yellow jaundice or pain, it can be relieved. Alternative Testing Alternative tests to ERCP include certain types of x-rays (CAT scan, CT) and sonography (ultrasound) to visualize the pancreas and bile ducts. In addition, dye can be injected into the bile ducts by placing a needle through the skin and into the liver. Small tubing can then be threaded into the bile ducts. Study of the blood also can provide some indirect information about the ducts and pancreas. Side Effects and Risks A temporary, mild sore throat sometimes occurs after the exam. Serious risks with ERCP, however, are uncommon. One such risk is excessive bleeding, especially when electrocautery is used to open a blocked duct. In rare instances, a perforation or tear in the intestinal wall can occur. Inflammation of the pancreas also can develop. These complications may require hospitalization and, rarely, surgery. Due to the mild sedation, the patient should not drive or operate machinery for six hours following the exam. For this reason, a driver should accompany the patient to the exam. ERCP Endoscopic retrograde cholangiopancreatography During this procedure an X-ray is taken of the pancreatic duct and bile ducts. These ducts drain secretions from the pancreas and liver respectively. Obtaining such pictures requires that an endoscope be placed in the mouth through the esophagus and stomach, then into the duodenum.

Procedure:

The patient is sedated and given potent pain relievers (opiate) after on overnight fast. A local anesthetic is sprayed to the back of the throat. Frequently, muscle relaxants are used to relax the duodenum and ampulla (an anticholinergic drug, or glucagon, nitroglycerin). During the test patients are monitored to ensure that they are not oversedated. The monitoring includes a pulse oximeter (a probe fastened to the patient's finger that measures blood oxygen concentration) and a heart rate monitor. During the ERCP, the degree of sedation is much greater than that used for an EGD, so often the patient is asleep. Using a modified endoscope, the investigator visualizes the duodenum on a monitor and finds the small opening where the bile duct and pancreatic duct empty into the duodenum (the ampulla of Vater). A thin catheter is passed through an opening in the endoscope and through the ampulla. Once the catheter has been placed through the opening (cannulated), a dye is injected into the pancreatic and bile ducts. This enables images of these ducts to be obtained. X-rays are taken of the abdomen over the area of the pancreas and are examined by the attending physicians on screen. Despite the medication, occasionally the patient may feel discomfort and may retch. If discomfort occurs additional pain relief is usually provided. Symptoms arising from complications may also rarely occur.

Accuracy:

Will show the indirect effects of pancreatic cancer such as blockage or dilatation of the ducts and inflammation of the tissue. Similar symptoms can be caused by conditions such as chronic pancreatitis or stones in the pancreatic or bile ducts. By examining the pattern of these changes, it is possible to predict with a high degree of certainty if an abnormality is a cancer. An ERCP can detect an abnormality suspicious of cancer in about 9 out of 10 patients who are investigated for possible adenocarcinoma. Patients who have very small cancers, less than 2 cm, that currently do not alter the main ducts of the pancreas or the bile duct will not be visible. Occasionally, it can be very difficult to tell if an abnormality in the pancreatic duct is due to cancer or inflammation. Tissue biopsy provides confirmation of the presence of cancer (link to FNA and cytology). This test is not useful in detecting most endocrine types of pancreatic cancer.

Results:

If the test results are abnormal, a sample of pancreatic fluid from the pancreatic duct or a sample of tissue by biopsy can be obtained if necessary. This can be done either during the ERCP by positioning a biopsy forceps while looking at it on screen. Alternatively, the fluid

or tissue sample can be obtained by visualizing the are of concern using other imaging techniques and performing a needle biopsy (FNA). As a treatment: Most importantly, if a pancreatic cancer is present and the patient is not a candidate for curative surgery, therapeutic procedures can be performed using ERCP. These procedures can provide considerable relief for the patient with minimal inconvenience or risk. Pancreatic cancers frequently block the bile duct that prevents the proper flow of bile from the liver. The therapeutic intervention typically alleviates symptoms caused by duct blockage such as jaundice, generalized and progressive itching, liver damage, inadequate digestion of food, a risk of bacterial infection of the blood and severe pain. Placing a stent into the bile duct to allow bile drainage can extend an individual's life and improve their quality of life. The patient does not feel the presence of the stent in their bile duct or pancreatic duct. The main complications of the ERCP as a diagnostic procedure are pancreatitis, infection and bleeding. The insertion of a therapeutic stent can have complications such as bleeding, inflammation of the pancreas (pancreatitis), bile duct damage and leakage, and infection. Bleeding and pancreatitis is more likely if a large (wide-bore) stent is placed as it requires a cut to be made to enlarge the opening of the narrow ampulla where the bile and pancreatic fluid enters the duodenum (see figure). The cut primarily targets a small sphincter muscle surrounding the ampulla (hence, the procedure is termed a sphincterotomy). Overall, less than 1 in 10 individuals will have such a complication and severe life-threatening complications are rarer (1-2%). The risk of a complication when a sphincterotomy is not performed is less (25%) and depends on the number and size of the stents inserted. Usually therapeutic ERCP can be done as a same day procedure without the need for an overnight hospital stay. If complications occur or are suspected hospitalization might be required. Biliary stents usually succumb to blockage after several months as a result of further cancer growth. This may require periodic stent replacement. There is also a small risk of an allergic reaction to the dye, which contains iodine. Rarely, drugs used to relax the ampulla of Vater can have side effects such as nausea, dry mouth, flushing, urinary retention, rapid heart rate (sinus or supraventricular tachycardia), or a drop in blood pressure.

Risks :

ERCP (Endoscopic Retrograde Cholangiopancreatography)

Endoscopic retrograde cholangiopancreatography (en-doh-SKAH-pik REH-troh-grayd koh-LAN-jee-oh-PANG-kreeuh-TAH-gruh-fee) (ERCP) enables the physician to diagnose problems in the liver, gallbladder, bile ducts, and pancreas. The liver is a large organ that, among other things, makes a liquid called bile that helps with digestion. The gallbladder is a small, pearshaped organ that stores bile until it is needed for digestion. The bile ducts are tubes that carry bile from the liver to the gallbladder and small intestine. These ducts are sometimes called the biliary tree. The pancreas is a large gland that produces chemicals that help with digestion and hormones such as insulin.
The digestive system

ERCP is used primarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP combines the use of x rays and an endoscope, which is a long, flexible, lighted tube. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x rays. For the procedure, you will lie on your left side on an examining table in an xray room. You will be given medication to help numb the back of your throat and a sedative to help you relax during the exam. You will swallow the endoscope, and the physician will then guide the scope through your esophagus, stomach, and duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum. At this time, you will be turned to lie flat on your stomach, and the physician will pass a small plastic tube through the scope. Through the tube, the physician will inject a dye into the ducts to make them show up clearly on x rays. X rays are taken as soon as the dye is injected. If the exam shows a gallstone or narrowing of the ducts, the physician can insert instruments into the scope to remove or relieve the obstruction. Also, tissue samples (biopsy) can be taken for further testing. Possible complications of ERCP include pancreatitis (inflammation of the pancreas), infection, bleeding, and perforation of the duodenum. Except for pancreatitis, such problems are uncommon. You may have tenderness or a lump where the sedative was injected, but that should go away in a few days. ERCP takes 30 minutes to 2 hours. You may have some discomfort when the physician blows air into the duodenum and injects the dye into the ducts. However, the pain medicine and sedative should keep you from feeling too much discomfort. After the procedure, you will need to stay at the hospital for

1 to 2 hours until the sedative wears off. The physician will make sure you do not have signs of complications before you leave. If any kind of treatment is done during ERCP, such as removing a gallstone, you may need to stay in the hospital overnight.

Preparation
Your stomach and duodenum must be empty for the procedure to be accurate and safe. You will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours beforehand, depending on the time of your procedure. Also, the physician will need to know whether you have any allergies, especially to iodine, which is in the dye. You must also arrange for someone to take you homeyou will not be allowed to drive because of the sedatives. The physician may give you other special instructions. Percutaneous transhepatic cholangiography

Definition Percutaneous transhepatic cholangiography (PTHC) is an x-ray test used to identify obstructions either in the liver or bile ducts that slow or stop the flow of bile from the liver to the digestive system. Purpose Because the liver and bile ducts are not normally seen on x rays, the doctor injects the liver with a special dye that will show up on the resulting picture. This dye distributes evenly to fill the whole liver drainage system. If the dye does not distribute evenly, this is indicative of a blockage, which may be caused by a gallstone or a tumor in the liver, bile ducts, or pancreas. Precautions Patients should report allergic reactions to: anesthetics dyes used in medical tests iodine shellfish

PTHC should not be performed on anyone who has cholangitis (inflammation of the bile duct), massive ascites, a severe allergy to iodine, or a serious uncorrectable or uncontrollable bleeding disorder. Patients who have diabetes should inform their doctor. Description PTHC is performed in a hospital, doctor's office, or outpatient surgical or x-ray facility. The patient lies on a movable x-ray table and is given a local anesthetic. The patient will be told to hold his or her breath, and a doctor, nurse, or laboratory technician will inject a special dye into the

liver as the patient exhales. The patient may feel a twinge when the needle penetrates the liver, a pressure or fullness, or brief discomfort in the upper right side of the back. Hands and feet may become numb during the 30-60 minute procedure. The x-ray table will be rotated several times during the test, and the patient helped to assume a variety of positions. A special x-ray machine called a fluoroscope will track the dye's movement through the bile ducts and show whether the fluid is moving freely or if its passage is obstructed. PTHC costs about $1,600. The test may have to be repeated if the patient moves while x rays are being taken. Preparation An intravenous antibiotic may be given every 4-6 hours during the 24 hours before the test. The patient will be told to fast overnight. Having an empty stomach is a safety measure in case of complications, such as bleeding, that might require emergency repair surgery. Medications such as aspirin, or non-steroidal anti-inflammatory drugs that thin the blood, should be stopped three-seven days prior to taking the PRHC test. Patients may also be given a sedative a few minutes before the test begins. Aftercare A nurse will monitor the patient's vital signs and watch for: itching flushing nausea and vomiting sweating excessive flow of saliva possible serious allergic reactions to contrast dye

The patient should stay in bed for at least six hours after the test, lying on the right side to prevent bleeding from the injection site. The patient may resume normal eating habits and gradually resume normal activities. The doctor should be informed right away if pain develops in the right abdomen or shoulder or in case of fever, dizziness, or a change in stool color to black or red. Risks Septicemia (blood poisoning) and bile peritonitis (a potentially fatal infection or inflammation of the membrane covering the walls of the abdomen) are rare but serious complications of this procedure. Dye occasionally leaks from the liver into the abdomen, and there is a slight risk of bleeding or infection. Normal results

Normal x rays show dye evenly distributed throughout the bile ducts. Obesity, gas, and failure to fast can affect test results. Abnormal results Enlargement of bile ducts may indicate: obstructive or non-obstructive jaundice cholelithiasis (gallstones) hepatitis (inflammation of the liver) cirrhosis (chronic liver disease) granulomatous disease pancreatic cancer bile duct or gallbladder cancers

Key Terms Ascites Abnormal accumulation of fluid in the abdomen. Bile ducts Tubes that carry bile, a thick yellowish-green fluid that is made by the liver, stored in the gallbladder, and helps the body digest fats. Cholangitis Inflammation of the bile duct. Fluoroscope An x-ray machine that projects images of organs. Granulomatous disease Characterized by growth of tiny blood vessels and connective tissue. Jaundice Disease that causes bile to accumulate in the blood, causing the skin and whites of the eyes to turn yellow. Obstructive jaundice is caused by blockage of bile ducts, while non-obstructive jaundice is caused by disease or infection of the liver.

What Is PTC?
Percutaneous transhepatic cholangiography, or PTC, is a way of examining the bile duct system in the liver. This procedure is done under local anesthesia by a radiologist. During the exam, a thin needle is inserted through the skin (percutaneous) and through the liver (transhepatic) into a bile duct. Then dye is injected, and the bile duct system is outlined on x-rays (cholangiography).

Why Is PTC Done?

Bile is a body fluid that helps your body digest fats. It is produced by the liver and collected in tiny bile ducts that empty into increasingly larger ducts. Finally, a main bile duct carries bile to the small intestine. Bile also is stored in the gallbladder. When one or more bile ducts narrows or has a blockage, bile may back up and cause problems

such as jaundice, a yellowing of the skin. Or, a leak in a bile duct may allow bile to flow into the abdominal cavity. PTC allows your doctor to see on the x-rays if the ducts are partially or completely blocked. If necessary, a thin, flexible tube (catheter) may be inserted to allow the bile to drain into a collection bag outside the body, or into the small intestine. This procedure is called biliary drainage. The drawing below shows the liver with the bile duct (biliary) tree, and the PTC needle inserted into a bile duct.

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY AND BILIARY DRAINAGE

continued
liver needle Bile duct (bile duct tree)

UPMC Health System Information for Patients

Before Your PTC Procedure

On the morning of your procedure, you may have a clear liquid breakfast, such as ginger ale or tea. Do not eat any solid foods. You will not be allowed solid food until after your PTC is over. You may continue to drink clear liquids. Before your procedure, a radiologist will visit you and describe the PTC procedure to you. He or she also will discuss biliary drainage with you in case you need to have this procedure done during the PTC. You will be asked to sign a consent form that gives your permission to have the procedures. You also will be asked if you are allergic to any medications, especially antibiotics or iodine. Be sure to tell your doctor and nurse if you have these allergies or if you have had any reactions to antibiotics or x-ray dye. This information will help your doctor and nurse to plan your care during the procedure. An intravenous (IV) line will be placed in a vein in your arm so that you can receive medications during the procedure. PTC is done in the Vascular and Interventional Radiology Laboratory on the first floor of Presbyterian University Hospital. You will be taken to the lab on a wheeled stretcher, and a nurse will help you get on the examination table. Patches will be placed on your chest and a blood pressure cuff will be placed on your arm so that staff may monitor your heart rate and blood pressure during the procedure. You will receive medications through your IV

to help you relax. You will be awake during the procedure and will be able to talk with those around you.

The PTC Procedure

The skin on the right side of your abdomen will be cleaned with special soap, and the area will be draped with sterile cloths. Your skin will then be numbed with a local anesthetic. Once the area is numb, the doctor will insert
duodenum (first part of small intestine) liver stomach common bile duct skin catheter

UPMC Health System Information for Patients

continued

a thin needle through your skin, between the ribs, through the liver, into a bile duct. As the needle is withdrawn, a small amount of dye will be injected and x-rays will be taken. If you have any discomfort, please tell your doctor or nurse. He or she can give you medication to relieve any discomfort you may feel. If the PTC results show a problem, such as a blockage in the bile duct, the doctor may replace the thin needle with a small drainage tube (catheter) that will be threaded into the small intestine (see illustration). A small pouch may be attached to the end of the catheter outside your body to collect bile. PTC usually takes about one hour to perform. If a drainage tube needs to be inserted, the procedure may take longer, depending on how easily the tube can be threaded through the bile duct.

After the Procedure

Following the procedure, your heart rate, temperature, breathing, and blood pressure will be checked frequently. The bile in the collection pouch also will be checked for color, amount, and presence of blood, and you will receive several more doses of antibiotic medication through your IV to prevent infection.

Going Home With a Catheter in Place

If you are to be discharged with a catheter in place, your nurse will teach you how to care for the catheter at home. You will learn how to change the bandage around the catheter, how to do daily irrigations through the tube (flushing the catheter with water), and what

to do about showering or bathing. Bandage Changes The bandage around the catheter will need to be changed every day, or any time it becomes soiled or wet. To change your bandage, first gather all the materials you will need and place them near you. Then wash your hands thoroughly with warm water and soap. To change the bandage, do the following steps: 1. Remove the old bandage. 2. Soak a cotton swab in hydrogen peroxide and clean carefully under the blue plastic disc that helps to secure the catheter. Be careful not to put any pressure on the catheter and not to pull on it at any time. 3. Inspect the skin around the catheter for redness, tenderness, or drainage. Also check to see that the catheter has not changed position. Call your doctor if you notice any of these signs. 4. Slit a 4-inch by 4-inch gauze square from one side to the middle of the gauze and place it around the catheter on top of the disc. Slit a second 4-inch-square gauze pad in the same way and place it around the catheter on top of the first bandage. Make sure the slits are on opposite edges when the pads are on top of each other. Do not place a gauze bandage under the disc; this could cause the catheter to pull out. 5. Cover the bandage completely with strips of sterile tape. Irrigations Your doctor may want your catheter to be capped. A cap, rather than a collection bag, on the outside end of the catheter will allow bile to flow directly into the small intestine. If the catheter is to be capped, you may need to flush (irrigate) the catheter periodically to keep it from becoming clogged. Your doctor will tell you if the catheter is to be capped. Ask your doctor if you will need to irrigate the catheter.
UPMC Health System Information for Patients
continued

Your doctor or nurse will tell you how to irrigate your catheter if it is capped. If fluid will not go into the catheter when you try to irrigate it, you should stop trying to irrigate the catheter and call your doctor immediately. Showering You may shower with the catheter in place, but you will need to cover the gauze bandage. To

cover the bandage, place a piece of plastic wrap over the bandage and tape all the edges of the plastic wrap to prevent water from seeping in. If the bandage becomes wet or damp, follow the steps listed previously to change the bandage.

Questions
Please share this information with your family, and ask your doctors and nurses any questions you or your family may have.
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Tests & Procedures

Cholecystography
(Gallbladder Series, GB Series, Oral Cholecystography, Oral Cholecystogram, X-rays of the Gallbladder)

Procedure Overview

What is cholecystography?
Cholecystography is an x-ray procedure used to examine the gallbladder when gallstones are suspected. A contrast dye is swallowed prior to the procedure. The contrast dye allows for better visualization of gallstones and other abnormalities of the gallbladder that cannot be seen on a standard x-ray of the abdomen. X-rays use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film. X-rays are made by using external radiation to produce images of the body, its organs, and other internal structures for diagnostic purposes. X-rays pass through body structures onto specially-treated plates (similar to camera film) and a "negative" type picture is made (the more solid a structure is, the whiter it appears on the film). Contrast dye, when swallowed prior to the cholecystogram, causes the gallbladder to appear opaque on a cholecystogram x-ray film. Gallstones will appear as dark spots within the gallbladder or bile ducts. Depending on how well the contrast dye has been absorbed, polyps and tumors may also be visible on the x-ray film. Due to the development of improved technology, cholecystography is no longer performed routinely. Ultrasound and computed tomography (CT scans) are faster and often more accurate in diagnosing conditions of the gallbladder. Other related procedures that may be used to diagnose problems of the gallbladder include abdominal x-rays, CT scan of the liver and biliary tract, abdominal ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), and gallbladder nuclear scans. Please see these procedures for

click image to enlarge additional information.

What are gallstones?

Gallstones form when bile stored in the gallbladder hardens into stone-like material. Too much cholesterol, bile salts, or bilirubin (bile pigment) can cause gallstones. Slow emptying of the gallbladder can also contribute to the formation of gallstones. When gallstones are present in the gallbladder itself, it is called cholelithiasis. When gallstones are present in the bile ducts, it is called choledocholithiasis. Gallstones that obstruct bile ducts can lead to severe or life-threatening infection of the bile ducts, pancreas, or liver. Bile ducts can also be obstructed by cancer or trauma. There are two types of gallstones: cholesterol stones and pigment stones. Eighty percent of gallstones are cholesterol stones. The size of gallstones varies from a grain of salt to golf-ball size. A person can develop a single stone or several stones.

What are the symptoms of gallstones?

At first, most gallstones do not cause symptoms. However, when gallstones become larger, or when they begin obstructing bile ducts, symptoms or "attacks" begin to occur. Attacks of gallstones usually occur after a fatty meal and at night. The following are the most common symptoms of gallstones. However, each individual may experience symptoms differently. Symptoms may include, but are not limited to, the following:

pain that comes and goes in the abdomen nausea and/or vomiting

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Gallbladder Mucocele
Last Updated: June 15, 2005

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Synonyms and related keywords: hydrops of the gallbladder, gallstone disease, overdistended gallbladder filled with mucoid or clear and watery content, outlet obstruction of the gallbladder, cholecystitis, Mirizzi syndrome, common bile duct obstruction, cholangitis

AUTHOR INFORMATION

Section 1 of 10

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Pictures Bibliography

Author: Rajagopalan Vijayaraghavan, MBBS, MS, MMed, FRCSEd, FICS , Consulting Surgeon, Department of Surgery, RMV Hospital, Bangalore, India Rajagopalan Vijayaraghavan, MBBS, MS, MMed, FRCSEd, FICS, is a member of the following medical societies: International College of Surgeons, and Royal College of Surgeons of England Editor(s): Oscar Joe Hines, MD, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael A Grosso, MD, Department of Cardiothoracic Surgery, St Francis Hospital; Paolo Zamboni, MD, Chair of Surgical Methodology, Assistant Professor, Department of Surgical, Anesthesiological, and Radiological Sciences, University of Ferrara Medical Center, Ferrara, Italy; and John Geibel, MD, DSc, Director, Professor, Departments of Surgery and Cellular and Molecular Physiology, Yale-New Haven Hospital, Yale University School of Medicine Disclosure

Author Info Introductio Indications Relevant A And Contraindic Workup Treatment Complicati Outcome A Prognosis Pictures Bibliograph

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Patient E

Cholestero

Gallstones Overview

Gallstones

Gallstones Symptoms

INTRODUCTION

Section 2 of 10

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Gallstones Treatment

Gallstone disease is the most common affliction of the biliary system, affecting 1520% of the US population, with nearly 1 million new cases reported annually. Problem: Mucocele or hydrops of the gallbladder describes an overdistended gallbladder filled with mucoid or clear and watery content. This usually noninflammatory distension results from an outlet obstruction of the gallbladder and is commonly caused by an impacted stone in the neck of the gallbladder or in the cystic duct. Frequency: About 3% of all pathologic gallbladders in adults are mucoceles. The true prevalence may be higher because of the varying criteria used by different

authors to define the condition. Reports indicate that an association could exist between mucoceles and solitary stones of the gallbladder. Etiology: Causes include the following:

Impacted stone in the gallbladder neck or cystic duct Spontaneously resolved acute cholecystitis Tumors - Polyps or malignancy of the gallbladder Extrinsic compression of the neck or cystic duct by lymph nodes or inflammatory fibrosis or adjacent malignancies in the liver, duodenum, or colon Prolonged total parenteral nutrition or ceftriaxone therapy Congenital narrowing of the cystic duct Parasites such as Ascaris (occasionally) In children and infants, acute, acalculous, noninflammatory hydrops of the gallbladder may be associated with the following: o Kawasaki syndrome (mucocutaneous lymph node syndrome) o Streptococcal pharyngitis o Mesenteric adenitis o Typhoid o Leptospirosis o Hepatitis o Familial Mediterranean fever o Nephrotic syndrome o Fibrocystic disease

Other problems to be considered include the following:

Hepatomegaly, choledochal cyst Courvoisier gallbladder due to simultaneous obstruction of the gallbladder and common bile duct Pseudocyst of the pancreas Renal mass Right suprarenal gland mass Mesenteric cysts Parasitic cysts - Hydatid cyst Ascending colon mass

Pathophysiology: Long-standing obstruction to the outflow from the gallbladder results in overdistension of the gallbladder; occasionally, the gallbladder assumes massive proportions and the volume may be as much as 1.5 liters. The bile or bile pigment is slowly resorbed, and continuing secretion from the mucosa of the gallbladder results in clear and watery or mucoid content (white bile). The wall may be of normal thickness, or, in long-standing cases, the mucosa atrophies and the wall becomes thin, sometimes even transparent. Wall thickening can occur with recurrent attacks of cholecystitis. The contents are usually sterile, and any bacterial contamination ends in empyema of the gallbladder. Gross overdistension may result

in gangrene and/or perforation of the gallbladder, with ensuing pericholecystic collection or peritonitis. The severity of the inflammatory episode dictates the clinical presentation. Microscopic examination reveals a flattened mucosa lined by low columnar or cuboidal cells; the increased intraluminal pressure results in plentiful RokitanskyAschoff sinuses. Inflammatory cells may be present either in small numbers or in abundance. Clinical: Symptomatology includes right upper quadrant (RUQ) pain or epigastric pain and discomfort, nausea, and vomiting. Continuance of pain or persistence of tenderness longer than 6 hours indicates possible acute cholecystitis. Fever and chills suggest infected bile, with a possible empyema of the gallbladder. Jaundice is unusual except in coexisting obstruction of the common bile duct either by stones or by extrinsic compression (Mirizzi syndrome). A palpable, somewhat tender mass is usual; the gallbladder at times may even be felt down in the pelvis. Diagnostic criteria The diagnosis of a mucocele should be considered in the following:

Minimal acute inflammatory signs are present. A large, palpable, minimally tender gallbladder is found on clinical examination. Laboratory test results are normal or just within the upper limit of reference range values. Plain radiograph of the abdomen shows a soft tissue density globular shadow in the subhepatic region. Ultrasonography of the RUQ shows evidence of minimal wall thickening, an impacted stone in the neck, or infundibulum of an enlarged gallbladder and clear content. Intraoperatively, the aspirate from the gallbladder is clear and watery or mucoid (white bile). The gallbladder on opening shows a white wall; clear, watery, or mucoid content; a stone or stones impacted in the neck or the cystic duct; a narrowed cystic duct; or a tumor and/or polyp causing obstruction of the neck of the gallbladder.
Section 3 of 10

INDICATIONS

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Pictures Bibliography

See Surgical therapy. RELEVANT ANATOMY AND CONTRAINDICATIONS

Section 4 of 10

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Pictures Bibliography

Relevant Anatomy: See Pathophysiology. Contraindications: The contraindications to surgical treatment of mucocele of the gallbladder obviously would include any associated medical conditions or illnesses that preclude surgery. No absolute contraindication exists. Laboratory research has indicated that chemical ablation of the gallbladder mucosa might be an alternative in patients who are medically unfit, elderly, or critically ill. A combination of ethanol, sodium tetradecyl sulfate, and a mucosal exfoliant has been tried successfully in rats. WORKUP
Section 5 of 10

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Lab Studies:

No single laboratory test is diagnostic of a mucocele. However, laboratory workup should i tests performed for acute cholecystitis.

A mild leukocytosis with a shift to the left is common. Higher counts indicate the possibility cholecystitis or infected bile. Bilirubin levels are usually within the reference range or may raised in cases of Mirizzi syndrome or in those with associated common bile duct (CBD) ob or cholangitis. Liver enzymes are usually within the reference range, although a mild rise in phosphatase may be present. Any gross rise should raise the suspicion of an obstructed C Serum amylase levels are generally within the reference range; any gross rise suggests th possibility of acute pancreatitis due to an obstruction close to the ampulla of Vater.

Imaging Studies:

Ultrasonography, although entirely operator dependent, is extremely sensitive in detecting the gallbladder. A grossly distended thin-walled gallbladder measuring over 5 cm across anteroposteriorly, an impacted stone in the infundibulum or neck of the gallbladder or in th duct, and clear fluid content indicate a possible mucocele. Sonographic Murphy sign may b positive. The wall may be thickened, and a small amount of pericholecystic fluid may be pr cases with acute cholecystitis. Gross wall thickening and murky, thick fluid with sediments pericholecystic collection suggest an empyema or pyocele of the gallbladder. Ultrasonogra also useful in identifying ductal obstruction and is extremely sensitive in identifying intrahep biliary tree dilatation.

Plain radiograph of the abdomen may show a soft tissue density shadow with an intralumin shadow in the subhepatic region. This finding alone is nonspecific and should only be used guideline in differential diagnosis.

Scintigraphy (hepato-iminodiacetic acid [HIDA] scan) may be indicated in obscure cases, a can only offer indirect evidence. Nonvisualization of the gallbladder indicates an obstructed gallbladder and possible acute cholecystitis; nonvisualization in the small intestine indicate obstruction.

CT scan may be indicated in cases where the diagnosis is unclear or where other associat conditions and/or complications must be assessed. The gallbladder is well visualized, and and contents can be assessed; however, stones may be difficult to identify. Associated he conditions, pancreatitis, and complications such as an abscess formation and perforation o gallbladder may be better assessed with a CT scan.

Magnetic resonance cholangiopancreatography (MRCP) clearly shows the biliary-pancrea and it is being used increasingly instead of a diagnostic endoscopic retrograde choledochopancreatography (ERCP) to assess the biliary tree; cholecystokinin (CCK)-enh studies are more specific.

Occasionally, percutaneous injection of contrast into the mass may be carried out to identi anatomical details. TREATMENT
Section 6 of 10

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Medical therapy: Do not consider a medical line of management with oral dissolution therapy in gallbladders. In acalculous hydrops observed in children as a part of a wider spectrum, expectant management may be considered.

Surgical therapy: Cholecystectomy is the definitive treatment for an obstructed gallbladder. Lap cholecystectomy is the criterion standard procedure. Open cholecystectomy may be performed in with very large gallbladders, those with greatly thickened walls, and those with an obliterated Calo in whom laparoscopic dissection could be difficult and time consuming.

In some patients, percutaneous (ultrasound-guided) or open cholecystostomy may be used as a measure; cholecystostomy is usually performed in very sick patients or when the dissection is tec very difficult. A subsequent completion cholecystectomy may be carried out once the initial condit improves.

Preoperative details: In patients with systemic signs and symptoms, preoperative management include correction of hydration, nasogastric drainage (if necessary), and appropriate broad-spectr antibiotic therapy. Preferably, cholecystectomy is carried out in the same admission.

Intraoperative details: Intraoperative aspiration of the large gallbladder helps to facilitate graspin gallbladder for dissection. Intraoperative cholangiography is indicated, depending on clinical and investigative features that suggest CBD obstruction. COMPLICATIONS
Section 7 of 10

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Progressive inflammation leads to acute cholecystitis and all its attendant manifestations. Bacterial contamination of the bile leads to an empyema of the gallbladder; the patient usu toxic and ill appearance. Gas-producing organisms may lead to an emphysematous gallbla bubbles in the wall of the gallbladder are visualized on plain radiograph, ultrasound, or CT

Perforation of the gallbladder with ensuing pericholecystic abscess or fluid collection and p is another complication; the diagnosis is usually strongly suspected on clinical grounds. Pseudomyxoma peritonei may result from the rupture of a true mucocele of the gallbladde Perforation of the gallbladder into the duodenum results in a cholecystenteric fistula. This o when the stone erodes into adjacent bowel, usually the duodenum. Gas in the biliary tree m evident on plain radiographs of the abdomen or on ultrasonography. If the stone is large, th result in obstruction of the distal small bowel, leading to gallstone ileus. Large gallbladders may compress on the pylorus or duodenum, causing gastric outlet obst
Section 8 of 10

OUTCOME AND PROGNOSIS

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The prognosis is excellent if diagnosis is correct and no complications have ensued.

For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Cen Cholesterol Center. Also, see eMedicine's patient education article Gallstones. PICTURES
Section 9 of 10

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Caption: Picture 1. Gallbladder mucocele. This is the ultrasound picture of a 35year-old woman presenting with recurrent episodes of right upper quadrant (RUQ) colic. Her most recent attack was 3 days ago. Note the gross wall thickening; this is usually measured on the anterior wall of the gallbladder on ultrasound examination. Also note the clear content, the stone in the neck of the gallbladder, and the absence of pericholecystic fluid. All favor a diagnosis of acute cholecystitis. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: CT Caption: Picture 2. Gallbladder mucocele. These pictures clearly show a stone in the neck of the gallbladder, with postacoustic shadowing. Also, the minimal wall thickening and a dilated gallbladder suggest a mucocele. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: CT

Caption: Picture 3. Gallbladder mucocele. This transverse scan of the gallbladder shows a stone in the neck of the gallbladder, with postacoustic shadowing. Also, minimal wall thickening and a dilated gallbladder are visible (see Image 2). View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: CT Caption: Picture 4. Gallbladder mucocele. These transverse scans of the gallbladder show layering of the gallbladder wall; this suggests edema and indicates an acute cholecystitis. View Full Size Image eMedicine Zoom View (Interactive!) Picture Type: CT Caption: Picture 5. Gallbladder mucocele. This longitudinal scan shows layering with fluid in the wall of the gallbladder and an impacted stone in the neck of the gallbladder. The intraluminal shadowing indicates sediments in the fluid; this image indicates acute cholecystitis with a possible pyocele of the gallbladder. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: CT Caption: Picture 6. This scan shows a cluster of impacted calculi in the neck of the gallbladder, minimal wall thickening, and clear content. This is indicative of a mucocele of the gallbladder. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: CT Caption: Picture 7. This scan clearly shows a cluster of calculi with postacoustic shadowing in the neck of the gallbladder, normal wall, and clear content; this

indicates a mucocele of the gallbladder. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: CT Caption: Picture 8. Gallbladder mucocele. This perioperative photograph of a gallbladder shows a distended gallbladder with evidence of adhesions on the wall of the gallbladder. The irregular surface indicates recurrent attacks of cholecystitis. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: Photo Caption: Picture 9. Gallbladder mucocele. This intraoperative photograph shows a subserosal perforation of an acute, emphysematous, acalculous cholecystitis in a 58-year-old diabetic man. He presented with features suggestive of ileus. He had a high intrathoracic liver (and gallbladder), and clinical signs were atypical. The green color is unusual. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: Photo Caption: Picture 10. Gallbladder mucocele. This perioperative photograph of a gallbladder shows the inflamed mucosa in a gallbladder; note the stones. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: Photo Caption: Picture 11. Gallbladder mucocele. This perioperative photograph of a

gallbladder in a patient with acute cholecystitis shows an inflamed, edematous gallbladder with areas of erythema and congestion. View Full Size Image

eMedicine Zoom View (Interactive!) Picture Type: Photo Caption: Picture 12. Gallbladder mucocele. This intraoperative photograph shows a yellowish aspirate from the gallbladder of a 28-year-old woman who presented with features of right upper quadrant peritonitis. The slightly yellowish fluid was sterile and was rich in cholesterol. View Full Size Image

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