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Gastroentrology > 2: Gall Stones, Cholecystitis, Cholangiocarcinoma > Flashcards

2: Gall Stones, Cholecystitis, Cholangiocarcinoma Flashcards

1
Q

What gender is most-affected by gallstones

A

Females (3:1)

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2
Q

What are the risk factors for gallstones (5F’s)

A

Female

Forty

Fair

Fertile: pregnant, COCP, HRT

Fat: + malabsorption bile salts

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3
Q

Where are the majority of bile salts re-absorbed

A

terminal ileum

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4
Q

What may cause malabsorption of bile-salts

A

Crohn’s disease

Ileal resection

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5
Q

What are pigment stones made of

A

Bile pigment

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6
Q

What is a risk factor for pigment stones and why

A

Haemolytic anaemia - increases Hb degradation and hence bile produced

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7
Q

How does gall stones usually present

A

Asymptomatic

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8
Q

For individuals who develop symptoms will gallstones, what is the most common presentation

A

Biliary colic

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9
Q

What will 35% of symptomatic individuals will gall stones develop

A

Acute cholecystitis

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10
Q

What causes biliary colic

A

Impaction of neck of the gallbladder by gallstone in cystic duct - that does not cause an inflammatory response or infection

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11
Q

How will biliary colic present clinically

A

Colicky RUQ pain. May be precipitated by consuming fatty foods. Associated with N+V

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12
Q

What causes acute cholecystitis

A

Impaction of gallbladder by gallstone in cystic duct which causes infection/inflammation

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13
Q

What sign is positive in acute cholecystitis

A

Murphy’s sign

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14
Q

Explain Murphy’s sign

A

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

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15
Q

What cause ascending cholangitis

A

Obstruction of common bile duct by gallstones which then leads to infection

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16
Q

What is the most common cause of ascending cholangitis

A

E.coli

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17
Q

What are 2 other organisms, aside from E.coli, that can cause ascending cholangitis

A

Klebsiella

Enterococcus

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18
Q

Who’s triad of symptoms presents in ascending cholangitis

A

Charcot’s triad

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19
Q

What is charcots triad

A

RUQ Pain
Jaundice
Fever

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20
Q

Why may patients in ascending cholangitis have pruritus

A

Due to accumulation of bile salts

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21
Q

How will
a. stools
b. urine
present in ascending cholangitis

A

a. pale stools
b. dark urine
= due to an obstructive jaundice picture

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22
Q

What are the symptoms of biliary colic

A

colicky abdominal pain

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23
Q

What are the symptoms of acute cholecystitis

A

colicky abdominal pain

fever

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24
Q

What are the symptoms of ascending cholangitis

A

colicky abdominal pain
fever
jaundice

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25
Q

What forms bile

A

cholesterol, phospholipids, bile salts

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26
Q

Where is bile stored

A

Gall bladder - then released into the duodenum on stimulation

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27
Q

What causes gallstones

A

Imbalance in components of bile

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28
Q

What are the 3 types of gallstones

A
  1. Cholesterol
  2. Pigment
  3. Mixed
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29
Q

What is the most common type of gallstone

A

Cholesterol (80%)

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30
Q

What are the risk factors for cholesterol gallstones (5F’s)

A 
Fat
Female
Forty 
Fertile
Fair
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31
Q

What percentage of stones are pigment

A

10%

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32
Q

What causes pigment stones to form

A

Haemolytic anaemias

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33
Q

What causes mixed stones

A

Bacterial infection

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34
Q

What blood tests may be performed in gall stones

A

LFTs, FBC, Blood culture

35
Q

How will FBC present in gall stones

A

Raised WCC in acute cholecystitis and ascending cholangitis

36
Q

How will CRP present in gallstones

A

Raised

37
Q

How will LFTs present in gallstones

A

Raised ALP

± raised GGT

38
Q

When are blood cultures performed

A

If suspecting ascending cholangitis

39
Q

What is the problem with blood cultures

A

Only +ve in 20%

40
Q

What is first-line imaging for presence gallstones

A

Abdominal-US

41
Q

How may AUS present in gallstones

A
  • presence gallstones
  • thickened GB wall
  • dilated biliary duct
42
Q

What is gold-standard for investigating gallstones

A

MRCP

43
Q

What is now used for diagnosis MRCP or ERCP

A

MRCP

44
Q

When is ERCP used

A

If ascending cholangitis - as it is both used for investigation and management

45
Q

Explain management of biliary colic

A
  1. Analgesia (NSAIDs)
  2. Risk factor reduction: exercise, diet.
  3. Elective laparoscopic cholecystectomy
46
Q

What time frame should an elective laparoscopy be offered

A

6W

47
Q

Explain management of acute cholecystitis

A
  • Fluids
  • Analgesia
  • Antibiotics
  • NBM
  • NG Tube for medications if vomiting
  • Laparoscopic cholecystectomy
48
Q

What antibiotics are given in acute cholecystitis

A

Co-amoxiclav

Metronidazole

49
Q

What time frame should laparoscopic cholecystectomy be performed in acute cholecystitis

A

48h

50
Q

How can ascending cholangitis present and what should be done in this case

A

Sepsis - initiate sepsis 6

51
Q

How should ascending cholangitis be managed

A
  • Fluids
  • Analgesia
  • ERCP and biliary decompression
52
Q

What antibiotics are used for ascending cholangitis

A

co-amoxiclav and metronidazole

53
Q

If patients are unfit for ERCP, what is performed

A

percutaneous trans-hepatic cholangiography (PTC)

54
Q

What are 4 complications of ERCP

A
  1. Pancreatitis
  2. Bleeding
  3. Perforation
  4. Cholangitis
55
Q

What are 5 complications of gall stone disease

A
  1. Pancreatitis
  2. Gallbladder empyema
  3. Gallstone ileus
  4. Bouveret syndrome
  5. Chronic cholecystitis
56
Q

What is gall bladder empyema

A

Collection of pus in gall-bladder, lead patients to be septic

57
Q

What is chronic cholecystitis

A

Recurrent acute cholecystitis - can lead to inflammation

58
Q

What is bouveret’s syndrome

A

Inflammation causes fistula to form between GB and duodenum. Gall stones can pass through and cause obstruction duodenum

59
Q

What is gallstone ileus

A

Presence large gall stones occluding terminal ileum

60
Q

What is cholangiocarcinoma

A

Cancer arising from the

61
Q

What age is cholangiocarcinoma more common

A

> 65

62
Q

In which region is cholangiocarcinoma more common and why

A

South East Asia.

As cholangiocarcinoma is associated with liver fluke (parasitic infection)

63
Q

How can risk factors for cholangiocarcinoma be divided

A

Gallbladder pathology

Or, Environmental

64
Q

What are 5 RFs of ‘biliary tract pathology’ that predispose to cholangiocarcinoma

A
  1. History Gallstones disease (75%)
  2. Primary Sclerosing Cholangitis (10%)
  3. Congenital - Caroli’s disease
  4. Porcelain gallbladder
  5. Adenoma
65
Q

What is a porcelain gallbladder

A

Intra-mural calcification of GB wall due to chronic cholecystitis

66
Q

What is caroli’s disease

A

Congenital defect - with dilation of intra-hepatic duct

67
Q

What is a risk factor for primary sclerosing cholangitis

A

Ulcerative colitis

68
Q

What are 4 environmental factors predisposing to cholangiocarcinoma

A
  1. Smoking, Alcohol
  2. Obesity
  3. Infection liver fluke
  4. Chronic cholecystitis
69
Q

What two infections most commonly result in chronic cholecystitis

A
  1. H.pylori

2. Salmonella

70
Q

How will cholangiocarcinoma present clinically

A

Asymptomatic until late stage - where it will present with jaundice, and obstructive jaundice picture

71
Q

What is the most common site of origin of cholangiocarcinoma

A

junction of left and right-hepatic duct

72
Q

What are tumours that arise at bifurcation of hepatic ducts called

A

Klatskin tumour

73
Q

What type of cancer are cholangiocarcinomas

A

adenocarcinoma

74
Q

What blood-tests are ordered for cholangiocarcinoma

A

LFT
CA19-9
CEA

75
Q

What imaging is ordered for cholangiocarcinoma

A

AUS
MRCP
CT

76
Q

What is gold-standard for cholangiocarcinoma

A

MRCP

77
Q

What is used CT used for in cholangiocarcinoma

A

staging of cholangiocarcinoma

78
Q

What staging system is used for cholangiocarcinoma

A

TNM

79
Q

What is primary management for cholangiocarcinoma

A

Surgery ± adjuvant radiotherapy

80
Q

If tumours are intrahepatic or klatskin, what procedure is indicated

A

Partial hepatectomy - with biliary tree resection

81
Q

If tumours are in the distal duct what surgical procedure is indicated

A

Whipple’s procedure

82
Q

What type of treatment do the majority of individuals with cholangiocarcinoma end up receiving

A

Palliative - only 10-15% present at an early enough stage for surgical management

83
Q

What does palliative treatment for cholangiocarcinoma involve

A

ERCP stenting

Palliative radiotherapy

84
Q

What is the prognosis for cholangiocarcinoma

A

12-18m from diagnosis

Gastroentrology (18 decks)

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