2: Gall Stones, Cholecystitis, Cholangiocarcinoma Flashcards
What gender is most-affected by gallstones
Females (3:1)
What are the risk factors for gallstones (5F’s)
Female
Forty
Fair
Fertile: pregnant, COCP, HRT
Fat: + malabsorption bile salts
Where are the majority of bile salts re-absorbed
terminal ileum
What may cause malabsorption of bile-salts
Crohn’s disease
Ileal resection
What are pigment stones made of
Bile pigment
What is a risk factor for pigment stones and why
Haemolytic anaemia - increases Hb degradation and hence bile produced
How does gall stones usually present
Asymptomatic
For individuals who develop symptoms will gallstones, what is the most common presentation
Biliary colic
What will 35% of symptomatic individuals will gall stones develop
Acute cholecystitis
What causes biliary colic
Impaction of neck of the gallbladder by gallstone in cystic duct - that does not cause an inflammatory response or infection
How will biliary colic present clinically
Colicky RUQ pain. May be precipitated by consuming fatty foods. Associated with N+V
What causes acute cholecystitis
Impaction of gallbladder by gallstone in cystic duct which causes infection/inflammation
What sign is positive in acute cholecystitis
Murphy’s sign
Explain Murphy’s sign
Apply pressure to RUQ - individual breathes in. If they have to stop inspiring due to pain it indicates acute cholecystitis. Only positive if negative on the left
What cause ascending cholangitis
Obstruction of common bile duct by gallstones which then leads to infection
What is the most common cause of ascending cholangitis
E.coli
What are 2 other organisms, aside from E.coli, that can cause ascending cholangitis
Klebsiella
Enterococcus
Who’s triad of symptoms presents in ascending cholangitis
Charcot’s triad
What is charcots triad
RUQ Pain
Jaundice
Fever
Why may patients in ascending cholangitis have pruritus
Due to accumulation of bile salts
How will
a. stools
b. urine
present in ascending cholangitis
a. pale stools
b. dark urine
= due to an obstructive jaundice picture
What are the symptoms of biliary colic
colicky abdominal pain
What are the symptoms of acute cholecystitis
colicky abdominal pain
fever
What are the symptoms of ascending cholangitis
colicky abdominal pain
fever
jaundice
What forms bile
cholesterol, phospholipids, bile salts
Where is bile stored
Gall bladder - then released into the duodenum on stimulation
What causes gallstones
Imbalance in components of bile
What are the 3 types of gallstones
- Cholesterol
- Pigment
- Mixed
What is the most common type of gallstone
Cholesterol (80%)
What are the risk factors for cholesterol gallstones (5F’s)
Fat Female Forty Fertile Fair
What percentage of stones are pigment
10%
What causes pigment stones to form
Haemolytic anaemias
What causes mixed stones
Bacterial infection
What blood tests may be performed in gall stones
LFTs, FBC, Blood culture
How will FBC present in gall stones
Raised WCC in acute cholecystitis and ascending cholangitis
How will CRP present in gallstones
Raised
How will LFTs present in gallstones
Raised ALP
± raised GGT
When are blood cultures performed
If suspecting ascending cholangitis
What is the problem with blood cultures
Only +ve in 20%
What is first-line imaging for presence gallstones
Abdominal-US
How may AUS present in gallstones
- presence gallstones
- thickened GB wall
- dilated biliary duct
What is gold-standard for investigating gallstones
MRCP
What is now used for diagnosis MRCP or ERCP
MRCP
When is ERCP used
If ascending cholangitis - as it is both used for investigation and management
Explain management of biliary colic
- Analgesia (NSAIDs)
- Risk factor reduction: exercise, diet.
- Elective laparoscopic cholecystectomy
What time frame should an elective laparoscopy be offered
6W
Explain management of acute cholecystitis
- Fluids
- Analgesia
- Antibiotics
- NBM
- NG Tube for medications if vomiting
- Laparoscopic cholecystectomy
What antibiotics are given in acute cholecystitis
Co-amoxiclav
Metronidazole
What time frame should laparoscopic cholecystectomy be performed in acute cholecystitis
48h
How can ascending cholangitis present and what should be done in this case
Sepsis - initiate sepsis 6
How should ascending cholangitis be managed
- Fluids
- Analgesia
- ERCP and biliary decompression
What antibiotics are used for ascending cholangitis
co-amoxiclav and metronidazole
If patients are unfit for ERCP, what is performed
percutaneous trans-hepatic cholangiography (PTC)
What are 4 complications of ERCP
- Pancreatitis
- Bleeding
- Perforation
- Cholangitis
What are 5 complications of gall stone disease
- Pancreatitis
- Gallbladder empyema
- Gallstone ileus
- Bouveret syndrome
- Chronic cholecystitis
What is gall bladder empyema
Collection of pus in gall-bladder, lead patients to be septic
What is chronic cholecystitis
Recurrent acute cholecystitis - can lead to inflammation
What is bouveret’s syndrome
Inflammation causes fistula to form between GB and duodenum. Gall stones can pass through and cause obstruction duodenum
What is gallstone ileus
Presence large gall stones occluding terminal ileum
What is cholangiocarcinoma
Cancer arising from the
What age is cholangiocarcinoma more common
> 65
In which region is cholangiocarcinoma more common and why
South East Asia.
As cholangiocarcinoma is associated with liver fluke (parasitic infection)
How can risk factors for cholangiocarcinoma be divided
Gallbladder pathology
Or, Environmental
What are 5 RFs of ‘biliary tract pathology’ that predispose to cholangiocarcinoma
- History Gallstones disease (75%)
- Primary Sclerosing Cholangitis (10%)
- Congenital - Caroli’s disease
- Porcelain gallbladder
- Adenoma
What is a porcelain gallbladder
Intra-mural calcification of GB wall due to chronic cholecystitis
What is caroli’s disease
Congenital defect - with dilation of intra-hepatic duct
What is a risk factor for primary sclerosing cholangitis
Ulcerative colitis
What are 4 environmental factors predisposing to cholangiocarcinoma
- Smoking, Alcohol
- Obesity
- Infection liver fluke
- Chronic cholecystitis
What two infections most commonly result in chronic cholecystitis
- H.pylori
2. Salmonella
How will cholangiocarcinoma present clinically
Asymptomatic until late stage - where it will present with jaundice, and obstructive jaundice picture
What is the most common site of origin of cholangiocarcinoma
junction of left and right-hepatic duct
What are tumours that arise at bifurcation of hepatic ducts called
Klatskin tumour
What type of cancer are cholangiocarcinomas
adenocarcinoma
What blood-tests are ordered for cholangiocarcinoma
LFT
CA19-9
CEA
What imaging is ordered for cholangiocarcinoma
AUS
MRCP
CT
What is gold-standard for cholangiocarcinoma
MRCP
What is used CT used for in cholangiocarcinoma
staging of cholangiocarcinoma
What staging system is used for cholangiocarcinoma
TNM
What is primary management for cholangiocarcinoma
Surgery ± adjuvant radiotherapy
If tumours are intrahepatic or klatskin, what procedure is indicated
Partial hepatectomy - with biliary tree resection
If tumours are in the distal duct what surgical procedure is indicated
Whipple’s procedure
What type of treatment do the majority of individuals with cholangiocarcinoma end up receiving
Palliative - only 10-15% present at an early enough stage for surgical management
What does palliative treatment for cholangiocarcinoma involve
ERCP stenting
Palliative radiotherapy
What is the prognosis for cholangiocarcinoma
12-18m from diagnosis
