Acute Cholecystitis
Cystic duct obstruction by gallstone; RUQ pain radiating to right shoulder, fever, leukocytosis, positive Murphy sign; ultrasound initial, HIDA gold standard.
Ascending Cholangitis
Charcot's triad (Fever, Jaundice, RUQ pain) + Hypotension and AMS = Reynolds pentad; life-threatening; emergent biliary drainage via ERCP.
Primary Biliary Cholangitis (PBC)
Autoimmune destruction of intrahepatic bile ducts in middle-aged women; severe pruritus, fatigue, antimitochondrial antibodies (AMA); Rx: Ursodeoxycholic acid.
Primary Sclerosing Cholangitis
Fibrous obliteration of intra- & extrahepatic ducts ('onion-skin' fibrosis, 'beaded' biliary tree on MRCP); strongly associated with Ulcerative Colitis.
The Gallbladder & Biliary Disease Spectrum
| Condition | Anatomical Obstruction Site | Clinical Manifestations | Diagnostic Strategy & Treatment |
|---|---|---|---|
| Biliary Colic | Transient stone impaction at cystic duct neck | Waxing/waning postprandial RUQ pain (< 6 hours); normal labs, no fever/peritoneal signs | RUQ ultrasound shows gallstones without wall thickening; elective outpatient cholecystectomy |
| Acute Cholecystitis | Persistent stone impaction in cystic duct leading to chemical and bacterial inflammation | Steady, severe RUQ pain (> 6 hours), fever, leukocytosis, positive Murphy sign (inspiratory arrest on RUQ palpation) | RUQ ultrasound (thickened gallbladder wall > 4 mm, pericholecystic fluid, sonographic Murphy); HIDA scan if equivocal; cholecystectomy within 72 hours |
| Choledocholithiasis | Gallstone retained within the common bile duct (CBD) | RUQ pain, jaundice, dark urine, acholic stools; elevated conjugated bilirubin and alkaline phosphatase | MRCP (magnetic resonance cholangiopancreatography) or EUS; therapeutic stone extraction via ERCP |
| Ascending Cholangitis | CBD obstruction with ascending bacterial infection (E. coli, Klebsiella, enterococci) | Charcot's Triad: Fever + Jaundice + RUQ pain; Reynolds Pentad: + Hypotension + Altered Mental Status (Septic shock) | Medical emergency: IV hydration, broad-spectrum antibiotics (Zosyn), and emergent biliary decompression via ERCP |
Hepatitis B Serology Master Interpretation
| Clinical Stage | HBsAg | Anti-HBs | Anti-HBc IgM | Anti-HBc IgG | HBeAg | Interpretation Pearl |
|---|---|---|---|---|---|---|
| Acute Hepatitis B | Positive | Negative | Positive | Negative | Positive | First marker to appear is HBsAg; Anti-HBc IgM signifies acute active viral replication |
| Window Period | Negative | Negative | Positive | Negative | Negative | HBsAg has dropped below detectable levels, but Anti-HBs has not yet risen; Anti-HBc IgM is sole marker |
| Chronic Infection (High replication) | Positive | Negative | Negative | Positive | Positive | HBsAg persists > 6 months; HBeAg indicates high viral infectivity and risk of transmission |
| Resolved Past Infection | Negative | Positive | Negative | Positive | Negative | Natural immunity: positive for both Anti-HBs (protective antibody) AND Anti-HBc IgG |
| Vaccination Immunity | Negative | Positive | Negative | Negative | Negative | Recombinant vaccine contains only HBsAg; patient is Anti-HBs POSITIVE alone |
OMM Board Correlate: Liver, Gallbladder & Celiac Viscerosomatics
- Liver & Gallbladder Sympathetics: Arise from T5–T9 on the right via the greater splanchnic nerve to the celiac ganglion. Acute cholecystitis produces hypertonicity and tissue texture changes at right T5–T9 paravertebral gutters.
- Chapman Point for Gallbladder: Anterior point is located in the right 6th intercostal space midclavicular; posterior point between transverse processes of T6 and T7 on the right.
- Right Phrenic Nerve (C3–C5): Gallbladder inflammation irritating the diaphragmatic peritoneum causes referred right shoulder pain along the supraclavicular nerve.
Board Traps & Common Distractors
- Patients with Primary Sclerosing Cholangitis (PSC) carry a drastically elevated lifetime risk of Cholangiocarcinoma (bile duct cancer) and Colorectal Cancer; annual colonoscopy with surveillance mucosal biopsies is mandatory.
- In Acute Ascending Cholangitis presenting with Reynolds pentad (Charcot triad + hypotension + confusion), medical management alone carries a near 100% mortality; emergent biliary drainage (ERCP with sphincterotomy or percutaneous transhepatic drainage) must occur within hours.
- Gallstone ileus is a mechanical small bowel obstruction caused by a large gallstone eroding directly into the duodenum through a cholecystoduodenal fistula; pathognomonic Rigler triad on abdominal radiograph: pneumobilia (air in biliary tree), small bowel obstruction, and ectopic gallstone (typically impacted in the ileocecal valve).