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gastroenterology , hepatology and nutrition > ***29. Gallbladder calculi .Cholecystitis. Cholangitis > Flashcards

***29. Gallbladder calculi .Cholecystitis. Cholangitis Flashcards

1
Q

what are the different terminology of gallbladder calculi

A

cholecystolithiasis = gallbladder stones

choledocholithiasis = extrahepatic bile duct

intrahepetic bile ducts

bile is formed from : bile acids / salts = made from cholestrol 
phospholipids - lecithin 
cholesterol 
bilirubin 
sodium , potassium , bicarbonate
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2
Q

what are the risk factors for gall stones ?

A 
four F 
fat 
FEMALES 
 OVER 40 
fertile

pregnancy

multiparity

lack of melatonin

imabalence of bile salt , lecithin , calcium carbonate and bilirubin

reduced gallbladder motility

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3
Q

descirbe cholestrol stones

A

MOST COMMON

radiolucent

there is excessive cholesterol and insufficient bile acid and lecithin (phopholipid) = percipitates to form cholesterol crystals and stones with calcium carbonate

they are whitish yellow

risk = four f
pregnancy

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4
Q

describe black pigment stones

A

causes - chronic hemolytic anemia , cirrhosis
= inrease circulating unconjugated bilirubin - increase uptake of this by the liver to conjugate - percipitation with calcium and unconjugated bilirubin = calcium bilirubinate

= cannot be dissloved = remove surgically

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5
Q

decribe brown pigmnets

A

risk - bacterial infection in the billary tracts due to bile staisi

catalyse the bilirubin glucuronide to insoluble unconjugated bilirubin = percipitaed calcum bilirubinate and BACTERIAL CELL BODIES

bacter

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6
Q

decribe mixed stones ?

A

mix of choestrol and pigmnet stones

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7
Q

what are the clinical signs and symptoms ?

A

asymtomatic
sometimes light epigastric pain and fat intolerance

post prandil pain after ingestion of fatty meal esp = vagal stimulation of gall bladder and release of cholecysokinin (hormone relased by the enteroendocrine cell of duodenum) - causing gall bladder to contract

if the stone gets stuck in ductus cysticus or and papilla vateri :
exrutiating billary colic constant dull RUQ pain lasting up to 6 hours
pain radiating to neck and right shoulder
nausea and vomitting

blocks the cystic duct
acute cholecystitis
fever
positive murphy sign

jaundice
excretion of bile pgments through kidney = dark urine colour
steatorrhea - grey

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8
Q

how do we diagnose gall bladder stones ?

A

golden stndard = ultrasound
endoscopic ultrasound
MRCP

CT diffrentiate pignet and cholesterin tsones
x ray - only dtect pigmnet stones = cholesterin stones = radiolucent

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9
Q

dd of gall bladder stone ?

A

kidney stone
ulcer
sclerosing cholangitis

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10
Q

wat is the treatmnet ?

A

clinically silent = no treatmet

symptomatic
begining of therapy = 24 hr fasting
after this dietary modification with decreased fat intake

NSAIDS

spamolytics - dycylomine

strong colic pain =
opiates - pethidin
(other morphine derivative causes spasm of sphincter of oddi )

udca = inhibto synthesis and secretion of cholestrol = for patients who refuse srugery or risky

dissolving gall stones of PURE cholesterol origin -with percutaneous catheter insertion - mono octanoin
or through a per oral catheter inserted into the common bile duct
should be less than 20mm

extracorpreal shock wave lithotripsy

when the acute systeoms stops
= laproscoic cholecystectomy
surgcal cholecystostomy

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11
Q

complications ?

A 
vitamin deficency of fat solublesubstance 
acute cholangitis 
pancreatitis 
empyema of gall bladder 
chronic cholecystitis
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12
Q

etiology of cholecystitis ?

A

there is acute calculus cholecystitis

etiology most often is cholelithiasis causing cystic duct obstruction - causing distention and inflammation of the gallbladder

secondary bacterial infection such as Coli and klebsiella maybe present

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13
Q

what is the clinical features of acute cholecystitis ?

A

right upper quadrant pain more severe and prolonged up to more than 6 hours

postprandial

fever

malaise

anorexia

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14
Q

physical signs of cholecystitis ?

A

positive murphy signs

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15
Q

what is a life threating form of cholecystitis ?

A

empheseymatous cholecystitis - air within the gall bladder formed by gas forming bacteria such as clostridium and coli

it is associates with early gangrene and gallbladder perforation

charteetristic feature when diagnosis - is air within the gallbladder - within ultrasound , CT

treatmnet : nothing should be taken by mouth
IV fluids
analgesice
broad spectrum iv antibiotics - piperacillin - tazobactum
meropenem
metronidazole

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16
Q

what is the diagnosis of cholecystitis ?

A

ultrasound : gall bladder wall thickening
gall bladder distention
glalbladder wall edema (double wall sign)
pericholecystic free fluid
presence of cholelithiasis

CT with contrast

we have to do severity grading

grade1 : mild acute cholecystitis no organ dysfunction or severe gallbladder disease

grade 2 (moderate) : no evidence of organ dysfunction
one of the flooring signs of severe gall bladder disease
symptoms duration of more than 72 hours
WBC >18,000/mm3
palpablee tender RUQ mass
inflammation on imaging studies

grade 3 severe acute cholecystitis 
dysfunction of one organ function 
either cardiovascular - hypotension 
neurological - impaired consciousness 
respiratory 
renal - oliguria and serum creatinine is more ethan 2mg/dl 
hepatic INR>1.5 
haematological - platelet count <100,000/mm3

==========

blood
CBC
CRP
BLOOD CULTURES

MILD ELVATION IN ast and ALT
cholestaisis - bilirubin , alp and ggt RISE IS UNCOMMON IN CHOLECYSTITIS IF PRESENTTHERE IS BILLARY OBSTRUCTION

mild elevation in lipase

17
Q

what is the treatmnet management of cholecystitis ?

A

grade 1 :early laparoscopic cholecystectomy
cefoxitin
moxifloxacin

grade 2 -
start empiric antibiotic -pepieracillin tazobactum
moxifloxacin
ertapenem

early laparoscopic cholecystectomy
discontinue antibiotics 24hrs after surgery

in grade 3 - start empiric antibiotic therapy
piperacillin tazobactum
meropenem
ertapenem

and continue with antibiotics after laparoscopic cholecystectomy
if there is a high surgical risk - urgent gallbladder drainage

18
Q

what are the complications of cholecystitis ?

A

gangrenous cholecystitis

gallbladder perforation

cholecystoenteric fistula

gallbladder - empyema

chronic cholecystitis

19
Q

etiology of cholangitis ?

A

choledocholithiasis

billary structures - congenital , infectious HIV
primary sclerosing cholnagitis
cholangiocarcinoma

20
Q

what is the clinical features of cholangitis ?

A

abdominal pain
high fever
jaundice - least common

hypotension
mental status change

21
Q

what is the diagnosis of acute cholnagitis ?

A

systemic inflammation - fever chilss
WBC and CRP high

signs of cholestaisis - jaundice
bilirubin , got , alp and alt high

imaging student such as ultrasound and CT with contrast - billary tract dilation , or thickening of bile duct
evidence of underlying , peridyctal edema
etiology
billary stricture or choledocholithiasis , cholangiocarcioa

========

put into grading same as acute cholecystitis

22
Q

treatment for acute chonagitis ?

A

grade 1 - empiric antibiotic therapy - alone sufficient
treatmnet of underlying disease

grade 2 - urgent billary drainage
treatment of underlying disease

grade 3
urgent billary drainage

billary drainage cane be ERCP GUIDED TRANSPAPILLARY

or EUS guided

gastroenterology , hepatology and nutrition (34 decks)

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