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| {{CMG}}; {{AE}} {{VR}}
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| ==Cholecystitis==
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| ===Definitions===
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| {|class="wikitable"
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| ! Terms!! Definitions
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| | Cholecystitis|| Cholecystitis is an inflammatory disease of the gallbladder.
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| | Acute cholecystitis|| Acute cholecystitis is an acute inflammatory disease of the gallbladder, most often attributable to gallstones.<ref name="Strasberg-2008">{{Cite journal | last1 = Strasberg | first1 = SM. | title = Clinical practice. Acute calculous cholecystitis. | journal = N Engl J Med | volume = 358 | issue = 26 | pages = 2804-11 | month = Jun | year = 2008 | doi = 10.1056/NEJMcp0800929 | PMID = 18579815 }}</ref><ref name="Reiss-1993">{{Cite journal | last1 = Reiss | first1 = R. | last2 = Deutsch | first2 = AA. | title = State of the art in the diagnosis and management of acute cholecystitis. | journal = Dig Dis | volume = 11 | issue = 1 | pages = 55-64 | month = | year = 1993 | doi = | PMID = 8443956 }}</ref>
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| | Acute calculous cholecystitis|| Acute calculous cholecystitis is an acute inflammatory disease of the gallbladder in the presence of cholelithiasis.<ref name="Strasberg-2008">{{Cite journal | last1 = Strasberg | first1 = SM. | title = Clinical practice. Acute calculous cholecystitis. | journal = N Engl J Med | volume = 358 | issue = 26 | pages = 2804-11 | month = Jun | year = 2008 | doi = 10.1056/NEJMcp0800929 | PMID = 18579815 }}</ref>
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| | Acute acalculous cholecystitis|| Acute acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder in the absence of cholelithiasis and has a multifactorial pathogenesis.<ref name="Huffman-2010">{{Cite journal | last1 = Huffman | first1 = JL. | last2 = Schenker | first2 = S. | title = Acute acalculous cholecystitis: a review. | journal = Clin Gastroenterol Hepatol | volume = 8 | issue = 1 | pages = 15-22 | month = Jan | year = 2010 | doi = 10.1016/j.cgh.2009.08.034 | PMID = 19747982 }}</ref>
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| | Chronic cholecystitis|| Chronic cholecystitis is a chronic inflammatory disease of the gallbladder with histological evidence of chronic inflammation like large range of related inflammatory epithelial changes including mononuclear infiltrate, fibrosis, thickening of muscular layer, dysplasia, hyperplasia and metaplasia.<ref name="Zhou-2013">{{Cite journal | last1 = Zhou | first1 = D. | last2 = Guan | first2 = WB. | last3 = Wang | first3 = JD. | last4 = Zhang | first4 = Y. | last5 = Gong | first5 = W. | last6 = Quan | first6 = ZW. | title = A comparative study of clinicopathological features between chronic cholecystitis patients with and without Helicobacter pylori infection in gallbladder mucosa. | journal = PLoS One | volume = 8 | issue = 7 | pages = e70265 | month = | year = 2013 | doi = 10.1371/journal.pone.0070265 | PMID = 23936177 }}</ref>
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| ===Acute Calculous Cholecystitis Diagnostic Criteria===
| | '''[[Acute cholecystitis resident survival guide|Click here for acute cholecystitis.]]''' |
| The [[Cholecystitis overview#Diagnostic Criteria|Tokyo guidelines]] is used in the diagnosis of acute calculous cholecystitis.<ref name="Takada-2007">{{Cite journal | last1 = Takada | first1 = T. | last2 = Kawarada | first2 = Y. | last3 = Nimura | first3 = Y. | last4 = Yoshida | first4 = M. | last5 = Mayumi | first5 = T. | last6 = Sekimoto | first6 = M. | last7 = Miura | first7 = F. | last8 = Wada | first8 = K. | last9 = Hirota | first9 = M. | title = Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 1-10 | month = | year = 2007 | doi = 10.1007/s00534-006-1150-0 | PMID = 17252291 }}</ref><ref name="Hirota-2007">{{Cite journal | last1 = Hirota | first1 = M. | last2 = Takada | first2 = T. | last3 = Kawarada | first3 = Y. | last4 = Nimura | first4 = Y. | last5 = Miura | first5 = F. | last6 = Hirata | first6 = K. | last7 = Mayumi | first7 = T. | last8 = Yoshida | first8 = M. | last9 = Strasberg | first9 = S. | title = Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 78-82 | month = | year = 2007 | doi = 10.1007/s00534-006-1159-4 | PMID = 17252300}}</ref>
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| | '''[[Chronic cholecystitis resident survival guide|Click here for chronic cholecystitis.]]''' |
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| ===Causes===
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| ====Life Threatening Causes====
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| Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
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| ====Common Causes====
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| ===Management===
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| {{familytree/start |summary=Cholecystitis}}
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| {{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms'''<br>❑ Abdominal pain</div>}}
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| {{familytree | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | | | | | }}
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| {{familytree | | | | | | | | | B01 | | B02 | | B03 | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">❑ Acute RUQ or epigastric pain<br>
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| ❑ Sharp, severe and steady pain<br>
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| ❑ Pain for >6 hours<br>
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| ❑ Pain radiating to right shoulder blade<br>
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| ❑ Pain after food intake<br>
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| ❑ Pain aggravated by movements<br>
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| ❑ Pain associated with nausea & vomiting<br>
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| ❑ Pain associated with diaphoresis<br>
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| ❑ Pain associated with fever<br>
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| ❑ Pain associated with anorexia<br>
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| ❑ Pain associated with mass in the RUQ<br>
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| ❑ Pain associated with Sx suggestive of [[Sepsis history and symptoms|sepsis]]<br>❑ Pain associated with Sx suggestive of Mirizzi syndrome<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ RUQ pain with fever & jaundice</div></div><br>❑ Pain associated with Sx suggestive of gallstone ileus<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ Transient abdominal pain with nausea & vomiting
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| :❑ Hematemesis</div></div></div>|B02=<div style="float: left; text-align: left; line-height: 150% ">❑ Acute vague abdominal pain<br>❑ RUQ mass<br>❑ Jaundice<br>❑ Fever</div>|B03=<div style="float: left; text-align: left; line-height: 150% ">❑ Recurrent biliary type abdominal pain<br>❑ Recurrent abdominal bloating<br>❑ Unstable stool with constipation/diarrhea</div> }}
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| {{familytree | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | C01 |-| C02 | | C03 | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<BR>❑ Febrile<BR>❑ Tachycardia<BR>❑ Dehydrated<BR>❑ Abdominal guarding<BR>❑ Murphy's sign<BR>❑ Abdominal creps<BR>❑ Abdominal tenderness<BR>❑ Reduced bowel sounds<BR>❑ Increased bowel sounds<BR>❑ Abdominal distension<BR>❑ Signs of sepsis</div>|C02=Consider DDx of '''acute acalculous cholecystitis'''|C03=Consider DDx of '''chronic cholecystitis'''}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | D01 |,| D02 |-| D03 |-|-|-|-|-|-|.| | | | | | | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase</div>|D02=No GBS/GB edema|D03=Consider evaluation for alternate diagnosis of abdominal pain}}
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| {{familytree | | | | | | | | | |!| |!| | | | | | | | | | | | | |!| | | | | | |}}
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| {{familytree | | | | | | | | | F01 |+| F02 |-| F03 |-| F04 | | |!| | | | | | | | | | | |F01='''Order urgent transabdominal USG (TAUSG)'''|F02=GBS w/o GB edema/GB edema w/o GBS|F03=HIDA scan|F04=GB opacity visualized}}
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| {{familytree | | | | | | | | | | | |!| | | | | |!| | | |!| | | |!| | | | |}}
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| {{familytree | | | | | | | | | | | |`| G01 | | G02 | | G03 | | |!| | | | | | | | | | |G01=GBS w/ GB edema|G02=GB opacity not visualized|G03=CT abdomen}}
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| {{familytree | | | | | | | | | | | | | |!| | | |!| | | |!| | | |!| | | | | |}}
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| {{familytree | | | | | | | | | H01 |-|-|^|-|-|-|'| | | H02 | | |!| | | | | | | | |H01=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic criteria:'''<ref name="Takada-2007">{{Cite journal | last1 = Takada | first1 = T. | last2 = Kawarada | first2 = Y. | last3 = Nimura | first3 = Y. | last4 = Yoshida | first4 = M. | last5 = Mayumi | first5 = T. | last6 = Sekimoto | first6 = M. | last7 = Miura | first7 = F. | last8 = Wada | first8 = K. | last9 = Hirota | first9 = M. | title = Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 1-10 | month = | year = 2007 | doi = 10.1007/s00534-006-1150-0 | PMID = 17252291 }}</ref><ref name="Hirota-2007">{{Cite journal | last1 = Hirota | first1 = M. | last2 = Takada | first2 = T. | last3 = Kawarada | first3 = Y. | last4 = Nimura | first4 = Y. | last5 = Miura | first5 = F. | last6 = Hirata | first6 = K. | last7 = Mayumi | first7 = T. | last8 = Yoshida | first8 = M. | last9 = Strasberg | first9 = S. | title = Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 78-82 | month = | year = 2007 | doi = 10.1007/s00534-006-1159-4 | PMID = 17252300 }}</ref><br>❑ Local symptoms & signs<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ Murphy’s sign
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| :❑ Pain or tenderness in RUQ
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| :❑ Mass in RUQ</div></div><br>❑ Systemic signs<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ Fever
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| :❑ Leukocytosis
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| :❑ Elevated CRP</div></div><br>❑ Imaging findings<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ TAUSG confirmatory finding of GBS & GB edema
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| :❑ HIDA scan confirmatory finding of GBS & GB edema </div></div></div>|H02=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic criteria:'''<ref name="Huffman-2010">{{Cite journal | last1 = Huffman | first1 = JL. | last2 = Schenker | first2 = S. | title = Acute acalculous cholecystitis: a review. | journal = Clin Gastroenterol Hepatol | volume = 8 | issue = 1 | pages = 15-22 | month = Jan | year = 2010 | doi = 10.1016/j.cgh.2009.08.034 | PMID = 19747982 }}</ref><BR>❑ Acute abdominal pain<BR>❑ Fever<BR>❑ Leukocytosis<BR>❑ Abnormal liver function tets<BR>❑ Imaging based criteria<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ [[Cholecystitis ultrasound#Imaging Criteria for Acalculous Cholecystitis|TAUSG based]]
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| :❑ [[Cholecystitis other diagnostic studies#Imaging Criteria for Acalculous Cholecystitis|HIDA scan based]]
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| :❑ [[Cholecystitis CT#Imaging Criteria for Acalculous Cholecystitis|CT based criteria]]</div></div></div>}}
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| {{familytree | | | | | | | | | |)|-|-| I01 |-| I02 | | |!| | | |!| | | | | | | |I01=W/ significantly elevated total bilirubin, alkaline phosphatase, ALT, AST &/or GGT|I02=Consider evaluation for alternate diagnosis like choledocholithiasis & cholangitis}}
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| {{familytree | | | | | | | | | J01 | | | | | | | | | | J02 | | |!| | | | | | | |J01='''Acute calculous cholecystitis'''<br>w/ or w/o complications|J02=Suspect '''acute acalculous cholecystitis'''}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | |!| | | |!| | | | | |}}
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| {{familytree | | | | | | | | | K01 | | | | | | | | | | K02 |-| K03 | | | | | | | | |K01=<div style="float: left; text-align: left; line-height: 150% "><BR>❑ Hospital admission<BR>❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ Empiric IV antibiotics<ref name="Solomkin-2003">{{Cite journal | last1 = Solomkin | first1 = JS. | last2 = Mazuski | first2 = JE. | last3 = Baron | first3 = EJ. | last4 = Sawyer | first4 = RG. | last5 = Nathens | first5 = AB. | last6 = DiPiro | first6 = JT. | last7 = Buchman | first7 = T. | last8 = Dellinger | first8 = EP. | last9 = Jernigan | first9 = J. | title = Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. | journal = Clin Infect Dis | volume = 37 | issue = 8 | pages = 997-1005 | month = Oct | year = 2003 | doi = 10.1086/378702 | PMID = 14523762 }}</ref><div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ Ceftriaxone 1 g IV every 24 hours or 2 g IV every 12 hours for CNS infections + Metronidazole 500 mg IV every 8 hours
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| '''or'''
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| :❑ Ciprofloxacin 400 mg IV every 12 hours/Levofloxacin 500 or 750 mg IV once daily + Metronidazole 500 mg IV every 8 hours</div></div><br>❑ Acute pain management
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| :❑ Ketorolac 30-60 mg IM/IV single dose
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| :❑ Opioids until cholecystectomy if ketorolac is contraindicated/pain not improving<br>
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| ❑ [[Cholecystitis overview#Severity Grading|Assess severity]]<ref name="Hirota-2007">{{Cite journal | last1 = Hirota | first1 = M. | last2 = Takada | first2 = T. | last3 = Kawarada | first3 = Y. | last4 = Nimura | first4 = Y. | last5 = Miura | first5 = F. | last6 = Hirata | first6 = K. | last7 = Mayumi | first7 = T. | last8 = Yoshida | first8 = M. | last9 = Strasberg | first9 = S. | title = Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 78-82 | month = | year = 2007 | doi = 10.1007/s00534-006-1159-4 | PMID = 17252300 }}</ref></div>|K02=Immediate biliary drainage|K03=Patient does not improve}}
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| {{familytree | | | | | | | | | |)|-|-|-|v|-|-|-|.| | | |!| | | | | | | | | }}
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| {{familytree | | | | | | | | | L01 | | L02 | | L03 | | L04 | | | | | | | | | | |L01=Grade 1 (Mild)|L02=Grade 2 (Moderate)|L03=Grade 3 (Severe)|L04=Patient improves}}
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| {{familytree | | | | | | | | | |!| | | |!| | | |!| | | |!| | | | | | |}}
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| {{familytree | | | | | | | | | M01 | | M02 | | M03 | | M04 | | | | |M01=Laparoscopic cholecystectomy within 72 hours|M02=<div style="float: left; text-align: left; line-height: 150% ">'''W/o complications & non high risk surgical candidates:'''<br>Immediate laparoscopic cholecystectomy + blood C&S ± bile C&S<br>'''W/o complications & high risk surgical candidates:'''<br>Immediate biliary drainage + blood C&S ± bile C&S<br>'''W/ complications:'''<br>Emergency laparoscopic cholecystectomy + blood C&S ± bile C&S ± appropriate surgeries for [[Gallstone ileus#Treatment|gallstone ileus]] & [[Mirizzi's syndrome surgery|Mirizzi syndrome]]</div>|M03=Emergency biliary drainage + blood C&S ± bile C&S|M04=Urgent laparoscopic cholecystectomy}}
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| {{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | | | N01 | | | | | | | | | | | |N01=Cholecystectomy after 3 months if GBS found during biliary drainage}}
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