Now, let’s take a few moments to talk about definitions here.
This is something when I was a student that would confuse me all the time.
So I wanna make sure that we’re all on the same page
before we get started talking about more complex material.
So Cholelithiasis, what does that mean?
Cholelithiasis means that there are gallstones in the gallbladder.
It doesn’t say anything about whether or not the patient has an infection
or anything along those lines.
It just means that there’s gallstones there.
Patients can have gallstones and actually not be symptomatic with them.
But all that means is that there are gallstones there.
So if you get an ultrasound report that says cholelithiasis,
just means there's gallstones.
Cholecystitis is the next definition to review.
So a cholecystitis means,
is it means that there is inflammation and infection of the gall bladder.
So this is when we get into the infection component.
So Cholelithiasis, just stones;
cholecystitis is inflammation and infection.
Cholangitis is the next definition.
So what cholangitis means, is it means that there’s obstruction
of the ductal system in the liver.
This leads to elevated pressures and infection.
The classic triad here we’ll talk about in a moment,
but fever, right upper quadrant pain, and jaundice.
So what are the common presenting complaints?
What do people come to the Emergency Department complaining of?
Right upper quadrant abdominal pain is a very common chief complain here.
And this is one of those pains that can radiate actually
to the right scapula or the right shoulder,
so the right posterior upper back or the right shoulder.
Patients oftentimes will have nausea and vomiting.
The pain may be worse after eating.
This is one of those situations where it’s very helpful to ask about
factors that provoke the pain and factors that make the pain potentially better.
So especially after eating fatty foods.
So you eat french fries and a burger, or something along those lines.
And the pain gets worst in that area,
that definitely supports the fact that there may be gallstones
or possibly even cholecystitis.
Fever mostly present in a situation of cholecystitis,
so if there’s that inflammation and infection there
that’s when the fever component would happen.
And then yellowing of the skin or the eyes
which means jaundice essentially.
So you wanna make sure you’re looking in the eyes,
looking at the skin closely, sometimes it can be hard to see.
Jaundice especially in patients who have darker skin tones,
but asking patients sometimes if they look different
than they look normally can help you there.
Sometimes I ask patients to see their license
if they described that they look different
or they feel like they look different so you can compare a little bit,
what they look like on a regular day to what they look like today.
And this is mainly something that occurs
when patients have that cholangitis component.
So when they have the blockages of the vessels of the ductal system within their liver.
What are we gonna see on our physical exam here?
Pain, tenderness in the right upper quadrant
and also a Murphy’s sign.
So what is a Murphy’s sign mean?
A Murphy’s sign is when you palpate in the right upper quadrant
and when you are palpating deeply
the patient stops their inspiratory effort.
And that’s associated with pain.
Other things to look for are jaundice or scleral icterus.
Scleral icterus is yellowing of the conjunctiva of the eyes.
You wanna make sure you're reviewing those vital signs.
You're looking for fever,
patients potentially who are very sick may have evidence of sepsis
and those patients would have a low blood pressure or an elevated heart rate.
Definitely you are looking for the fever in that area as well.
Now, Charcot’s Triad is something that supports the diagnosis of cholangitis.
So the triad consists of fever, plus right upper quadrant pain plus jaundice equals Charcot’s Triad.
You can also add in hypotension and altered mental status.
If you add those in it equals Reynold’s Pentad.
Cholangitis is one of those diagnoses that you wanna be sure not to miss.
Patients can be very, very ill when they have cholangitis.
So if you're worried about this diagnosis
definitely be thinking about this triad as well as the Pentad.