Diagnosis. Right upper quadrant
tenderness we talked about,
along with this, there’s something
called Murphy’s sign.
What does that mean? It means
that the pain is then going to
shoot up into the right scapula
for the Murphy’s sign.
The gallbladder is usually not
palpable. Leukocytosis and
elevated liver function test.
Now, we’re getting to interesting labs.
If in fact it is going to be
issues in the biliary tree,
what’s the enzyme that you’re
paying attention to?
If you have issues in the
liver, you have alk phos and
liver function test, such as
Let me give you another one.
What if it was alk phos and lipase?
Where is my stone, please?
The stone has moved down
to the common bile duct.
Not only do I have problems
with the biliary tree,
but I also have damage
and pathology to the pancreas.
Things that you’re worried about,
blood cultures show E.coli.
Gram-negative organisms we talked
about. Maybe even Clostridium.
Imaging. The type of radiology and
imaging study that you’d use, ultrasound.
The gallstones are symptoms that you would
find inside my gallbladder.
In addition, remember, if the gallbladder
has been obstructed, you can imagine
that the gallbladder wall has
become inflamed. Therefore,
you’d expect to find thickening
and edema of the gallbladder wall.
In fact, histologically, when the
gallbladder has become thickened
and cholecystitis continues, at some
point in time -- have you heard?
I know that you have. In medical school
and during your education,
you’ve heard of something called
What color is porcelain? White.
Gallbladder is not that color normally.
So what is then contributing to the
whitishness of the gallbladder,
The thick wall at some point
might start eroding.
If you have erosion, there's s a term, that
will be called or known as Rokitansky,
Rokitansky type of sinus. And with that
Rokitansky type of sinus that develops,
you might have calcium accumulating,
and this is dystrophic calcification.
Calcium is what color?
Ultrasound will show you gallstones
in the gallbladder, thickening of that wall
with edema. And you have something
called your dilated biliary tree.
You’re going to like this one. You’re
going to bring in some anatomy,
you’re going to know some physio,
and we’re going to use pathology
so that we can use something
called a HIDA scan. Pay attention.
Stone, gallbladder, think about
what that is.
cholecystitis, maybe Rokitansky
type of sinus that we talked about.
Ultrasound is going to help
you identify the gallstone.
Now, here’s my problem.
I don’t find a stone.
Oh, boy. I don’t find a stone
perhaps in the gallbladder.
But you know there’s obstruction
based on the symptoms of your patient.
But you don’t know
where the stone is.
You don’t know if the stone is
located in the cystic duct
or if the stone is down the
common bile duct.
If you’re not clear about this anatomy,
I mentioned this earlier,
I asked you kindly to make sure
that you’re familiar with
at least the basic anatomy here to walk
us through these type of imaging studies
that you’ll be asked about on your boards.
Your HIDA scan. Remember, from the
liver is where bile synthesis takes place.
It will be taken to the bile
duct in the liver, out of the liver,
and into the gallbladder, normally.
What if you had a method by
which you injected a dye,
hepatic endo-diacetic acid.
You had a dye. HIDA stands for
hepatic endo-diacetic acid.
Do not worry about the name per se.
It’s the dye that you’re
putting into the liver.
You’re going to radiographically
follow the dye and see as to
whether or not it should end up
in your gallbladder. Are you with me?
What if the stone is in the cystic duct?
Go back and take a look at the anatomy.
If that stone is in cystic duct,
is that dye going to make its way
from the liver to the gallbladder? No.
Therefore, useful in doubtful
cases of cholecystitis,
because this will tell you if the
cholecystitis was being caused by a stone
in the cystic duct. And if the dye
doesn’t make it in the gallbladder,
this confirms that your
stone and the cholecystitis
was caused by the stone
in the cystic duct.
It couldn’t be any clearer than that.
If that still remains confusing,
go back and review what I just
said here because that part,
I guarantee, you’ll be asked about
that in some way, shape, or form.
Ultrasound, HIDA scan.
Ultrasound of the gallbladder.
That arrow that we’re seeing
here on the ultrasound is
actually showing you a stone
within the gallbladder.
Let’s take a look at the
management of gallstones.
Patient comes in and says, “Hey,
doc, I had a piece of steak
and, aw, it hurts.” “Where?”
“Right upper quadrant pain.”
He asked a surgeon and what
does he or she want to do?
Cholecystectomy, remove it. However,
you will go and step further.
Your patient is not, NOT, symptomatic.
Therefore, you will not be
doing surgery, period.
Elective surgery is a possibility
if there’s complications.
Next, whenever there are issues
within or -itis in general,
IV antibiotics and hydration
because you’re worried
about once again, sepsis.
Percutaneous drainage for acalculous
type of cholecystisis and ERCP,
an urgent type of decompression, with
what’s known as a sphincterotomy,
in which you try to then evacuate
the stone as quickly as possible,
especially if he's then prone
Remember when to use a HIDA scan
and when to do an ERCP.
HIDA scan is when you find
a cholecystitis and you’re
doubtful about where the stone is
and you find it in the cystic duct.
And ERCP would be one in which
emergency-wise, you try to remove
the stone as quickly as possible
so that you allow for proper flow
of your bile and your pancreatic
enzymes into the duodenum.