 The next topic we're going to be talking about today is Cholidocholithiasis. Now, we just talked about Cholicistitis in the last lecture. Now, the story continues. For Cholidocholithiasis, I want you to just realize it's the continuation of the story of Cholicistitis and also Cholilithiasis. Cholilithiasis was a stump. This stone obstructed the cystic duct. We call it Cholicistitis when it had the gallbladder inflate. This stone no longer lives here. Somehow, some of the stone will manage to get through. And now it's obstructing the common bowel duct. See how I told you from the beginning that everything that has to do with the gallbladder starts with the anatomy. So, there's something special about Cholidocholithiasis. Let's start. On history, when the patient comes in, they're going to come to the ER and they're going to tell you, Doc, have you had a rightful quadrant pain? Also, we're getting into my scapular. I'm having some epigastric pain. Right? Then you ask them, what else is wrong? They're like, my eyes are yellow. They've got yellow eyes. Now you've got a clue. I had the patient last time. He came to the ER exactly like that. Rightful quadrant pain, epigastric pain is that bilateral sclerotecterus, which is basically yellow eyes. I'm looking at the lady, I said, hmm, look at that. You're spilling bilirubin. She's like, why is my eyes yellow? I knew the answer. I knew she's spilling bilirubin. Now let's go over the pathology. Now look at the liver. The liver automatically processes bilirubin. Right? Bilirubin has to travel and go inside here. However, when you have a stone obstructing the column by a dot, all the bilirubin start to back up and back up and back up. Whoops. He goes into the central vein. When he gets into the central vein, he goes straight into the apathic vein, which eventually he dumps into the IVC. Now here's a catch. First history, right? Upper quadrant pain, or epigastric pain. The nausea, the vomiting. They tell you the eyes are yellow, right? Yellow eyes. In medicine, we call that sclerotecterus, which is a financing name for yellow eyes, right? Then you wonder, nausea, vomiting, the right upper quadrant pain, epigastric pain, and jaundice, right? The reason why they have that, the difference, right, between acute cholecystitis and acute cholecolythiasis, this is right upper quadrant pain with no jaundice at all. You know why? Because when you obstruct the cystic duct, you don't spill, you can't even get the bilirubina, right? However, if you're obstructing the common body duct, the bilirubina is able to go here, but it has nowhere to go. And all of a sudden it backs up. You ask them, how's your poop? You. Yeah, I know. It's clay collared. Clay collared stool. Why is this stool clay collared? It doesn't have any collared. What do you think gives your poop that brown, whatever collared comes out to be, is because of the what? Is the bilirubin and the bile acids. That's what gives the costal stool collared. So if you're not able to spill it and go to the dryer and I'm going to form the poop all the way out, it backs all the way into the, back into the peripheral system, your stool ain't going to have the nice fancy collared. I know. Nothing really curious there, right? Oh, jeez. So gross. Anyway. But, guess what's going to eventually happen? All this bilirubin is backing up, backing up, backing up. It's going to your bloodstream. Now the blood, it's going to go through the kidneys. When it gets into the kidneys, we've got a problem. It's going to spill out the bilirubin and now it's going to give your urine dark collared urine. Isn't it funny? When you understand where things are going and how things are ending up, you realize it's not that hard. The adjoin is dark urine. Click on the stool. If the bilirubin is so much, bile salts cause you to itch. It causes a lot of itching. Can I tell you? Oh my God. I've been itching a lot. Not cold. Itching, yellow, right up a quarter on pain. Right? Tondis, colidocolithiasis. So, now that you've got the history, a physical exam, what are you going to do? You pop it on the belly. You push down. Tell it to take a deep breath. It hurts when I do that. They might have Murphy's sign, but it's not always there. Always remember. But the difference is to know how to make the diagnosis. Now, to make the diagnosis, we need to order labs. So what labs are we going to order? The first thing you want to get, I want to get a liver function test. A-S-D-A-L-T. You also want to get also G-G-T and alkylophosphatase. When you get a positive A-L-P, you can get an alkylophosphatase. If you haven't watched the video, check back on alkylophosphatase and liver function test videos that we made. G-G-T, which is gamma glutamate transferase, is extremely specific to the what? To the gallbladder, to the biliratory. A-F-A-S-T, you can find the placenta, you can find the bone, but a G-G-T-A-L-T is still coming from the gallbladder. It might be elevated in ALT if you get some mild inflammation, but it's usually not. It's usually coming from ALT and G-G-T. You can order a CBC to check their white count, right? To see what their white count is. If it's high, it's telling us something wrong. If they have a fever, oh, it's taking us a different pathway, which we're going to talk about in the next lecture, but let's focus on this. Because one of the complications might lead us to tell us something different from the CBC that we don't really expect. Now after we've ordered that, and we know definitely this is a gallbladder pathology, how do we make the diagnosis? The diagnosis and the treatment have pretty much the same. Let's do this. Diagnosis, E-R-C-P, right? Endoscopic, retrograde, colonio pancreatography, right? What they do, normally how they do this procedure is they'll take a scope that goes all the way into your stomach, goes all the way and now makes a U-turn and goes right into the column about that. They observe it, they'll be able to see the stone. And guess what, see the stone? They can pluck it out and pull it out. So that's called E-R-C-P plus sphincterectomy. That's the treatment. Right? They take a scope, put it on your throat, it goes all the way down, goes into the duodenum, always makes a U-turn, goes through the sphincter of Audi, pluck it out, and that's it. Voila, I'm done. If that doesn't work, we can do a laparoscopic colidocolithotomy. But that's usually done in very select cases. E-R-C-P is usually your mode of treatment and you're good to go and the patient feels better and they say, doc, thank you. Can I go home now? You say, yeah, good. Now, because there are complications to colidocolithiasis, we need to talk about those complications and one of the complications is what? Ascending colongitis. So, ascending colongitis. Let's talk about that for a second. This is one of the complications for colidocolithiasis. I'm going to tell you a little story. Let's go back to our picture here. Inside your duodenum is a lot of poop, right? It's not really the nicest thing. They look nice when you're eating them, though, until they get digested. And inside there's a lot of bacteria. So, the definition of ascending colongitis is what? Something is going up, right? Through the steps, right? Affecting the coal. Again, biliary tree, right? Coal-y, biliary cobalter. Aides, again, inflammation. In this case, what's causing the inflammation is an infection. So, an infectious process creeping up into this green line which is the common bowel duct is called ascending colongitis. What do you think is causing it? Bacterial overgrowth. Now, let's talk about the guys that are actually playing a role in this. And I love this story. So, one day, E. coli clapsiella proteas pseudomonas enterococci enterococci they were just hanging out a couple of buddies, right? They were just hanging out. So, I call them the sick P. P. mnemonic erasure, enterococcus, E. coli, clapsiella, proteas, and pseudomonas. This are what? Gram-negative bacteria. They were just hanging out in your colon, right? And all of a sudden, they're creeping up and creeping up, and there's a little hole. They're like, man, yo, E. coli, you wanna go check that place out? They're like, yeah, I'll go check what's up, man. E. coli clamps through the little hole, goes up. This is something that's like, fellas, I can't really see. But, y'all wanna come up here and see stuff? These buddies come with him. They ascended. They climbed the stairs. They all climbed the stairs. Now they end up into what? They get into the billiard tree through this beautiful hole. And now they're having sex. Mating. Bacteria overgrowth. Now you've got an infection. So now we know the cause. Let's talk about the history. What is the patient gonna present with? We actually have to erase this and talk about something very important. What are the chocolates? Fever. Right up a quadrant on this. Now, this doesn't really require a lot of memorization. Because I told you, we talked about colidocolithiasis. And one of the complications of colidocolithiasis is if the stone gets stuck there long enough bacteria can come up there. They're having sex. They're growing. So now, I'm not surprised with the right up a quadrant of pain because that's where the stone coming from, right? I'm not talking about the journeys of thousands of journeys. They're really not enough to bring it out over. It's the fever. Because fever, right up a quadrant of pain in journeys is called the classic triad usually 50 to 70 percent of patients. This is an emergency. I do not want my patients to be journeys right up a quadrant of pain in a fever. And that's bad. So what do we want to do? Order labs. When we order labs I know that thing before actually we order labs Chuckles triad is this three. We can expand it to Reynolds triad. And I can tell you if you think Chuckles is bad Reynolds is even worse. And I'm going to explain exactly why Reynolds is bad. So now the bacteria having sex right? You think that's cool? No it's not. Because when this bacteria gets into the bloodstream now you've got a problem. You get into CERS Systemic Inflammatory Response Syndrome right? You become tachycardic a heart rate greater than 90, right? You get a fever. Now all of a sudden your white count goes up about more than 12,000. It's not the end of the world. You think that's bad enough? You can't talk hypnic. You have to hyperventilate. Guys, it's really bad. You get warm skin. You go into sepsis. Eventually bacteria because we're going to actually talk about sepsis and septic shock you go into septic shock, right? Systemic Visibilitation all of a sudden you get all the mental status. Now that's called a Reynolds triad Pentate. Which is the extreme of a Chuckles triad. Because remember the fever is because the bacteria are coming in and the new trophies are traveling infiltrate and now the bacteria's context is broken apart that's what started to cause the CERS that I talked about, Systemic Inflammatory Response Syndrome and eventually people develop ultimate status and all that. You don't want that to happen. So what do you want to do? When we order labs, you're going to see the elevated bilirubin, right? Conjugated bilirubin is going to be high. Just as in collidocholithiasis LFTs, you check what? You check ALP, alkaline phosphatase it's going to be elevated. GGT is going to be elevated. Do you think you're going to have a white count? Yeah, that's what was trying to tell you before. The white count. The white count. Why do we order CBC? Because now we got a shift which means new trophies are coming in, right? Lab wise LFTs we get alkaline phosphatase and we get a GGT. Conjugated bilir and if you don't know why we're saying it's conjugated because the liver already processed it. The UDP glucoloneal transverse already added glucoloneal as we're conjugated your bilirubin so all of a sudden it becomes water soluble and it's able to come out into the gallbladder. So it's already conjugated. It's not an intrepid problem. This is more coming outside here, right? So the conjugated bilirubin will be high. We got a white count we see WBC is going to be elevated maybe with increased left shift a lot of neutrophils. We got a lot of neutrophils. That is badness. So what do we want to do? How do we treat this patient? You can do what you want to do. The next thing you want to do is get an ultrasound. You ultrasound the belly the belly is going to also show you the coli-ducalithasis ERCP is what we have to do. We have to drain this. Right? But before we do that we still got to order more labs for blood culture. Why do I want to get blood culture? I just told you E. coli and his friends are made. So I want to be able to see them exactly what antibiotic I got to give. I'm worried because this guy might go into sepsis and go into shock soon. So we'll give them IVF. Remember this is an infection what do we use to treat infection? We give them antibiotics. Now the most important thing is to do an endoscopic retrograde pancreato-colongeography ERCP What is the point of that? Because the ERCP like I told you we're going to put a scope down there we go all the way into the sphincter of OD and now we can suck the stone and also suck out all those little dirty stuff. Okay? That is extremely important. We decompress this common balda because it's probably already distended. We use a catheter and we do a sphincterotomy. Okay? Also sometimes they put a T-tube in there so for drainage for especially a lot of people that don't respond to antibiotics. So the problem is this is a very serious emergency. Okay? One of the biggest complications of colidol-colithiasis. Keep this in mind and don't forget. Thank you.