7.01 - HPB Gall Bladder Flashcards

1
Q

What is the pathophysiology of gallstones?

A

Bile is formed from cholesterol, phospholipids and bile pigments, and stored in the gallbladder.

Gallstones form as a result of supersaturation of bile. There are three main types of gallstones:

1) Cholesterol stones - composed purely of cholesterol, link between poor diet and obesity

2) Pigment stones - composed purely of bile pigments, from excess bile pigment production (haemolytic anaemia)

3) Mixed stones - comprised of bile pigments and cholesterol

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2
Q

What are the risk factors for gallstones?

A

5 Fs:

Female
Fat
Forty
Fertile
Family history

Pregnancy
Oral contraceptives*
Haemolytic anaemia
Malabsorption

*Oestrogen causes more cholesterol to be secreted into bile.

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3
Q

What is biliary colic? Give the clinical features?

A

Biliary colic occurs when the gallbladder neck becomes impacted by a gallstone. There is no inflammatory response, but contraction of the gallbladder (CCK) results in pain.

Pain is sudden, dull, and colicky in nature.
RUQ pain
Precipitated by consumption of fatty foods

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4
Q

What is acute cholecystitis? Give the clinical features.

A

Acute cholocystitis occures when the gallbladder neck becomes impacted by a gallstone AND there is associated inflammation.

The patient reports a constant pain in RUQ or epigastrum, with fever and lethargy.

OE tender in RUQ; Murphy +ve; ?guarding (perforation); ?sepsis

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5
Q

What is Murphy’s sign?

A

When applying pressure in RUQ, ask patient to inspire; if patient halts when inspiration this indicated inflammed gallbladder.

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6
Q

How are gallstones investigated?

A

FBC & CRP to assess for inflammatory response (cholecystitis)

LFTs - raised ALP due to ductal occlusion, but ALT and bilirubin should remain within normal limits.

Amylase to check for pancreatitis

Urinalysis, including pregnancy test, to exclude renal or tubo-ovarian pathology.

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7
Q

How are gallstones investigated?

A

FBC & CRP to assess for inflammatory response (cholecystitis)

LFTs - raised ALP due to ductal occlusion, but ALT and bilirubin should remain within normal limits.

Amylase to check for pancreatitis

Urinalysis, including pregnancy test, to exclude renal or tubo-ovarian pathology.

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8
Q

How are gallstones imaged?

A

Trans-abdominal ultrasound first line.

Magnetic Resonance CholangioPancreatography (MRCP) is gold standard if USS inconclusive.

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9
Q

How is biliary colic managed?

A
  • analgesia
  • lifestyle factors (weight loss, increasing exercise, low fat diet)

Elective laparoscopic cholecystectomy is definitive management.

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10
Q

How is acute cholecystitis managed?

A
  • IV abx (e.g. co-amoxiclav)
  • analgesia
  • anti-emetics

Laparoscopic cholecystectomy within 1 week.

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11
Q

What is Mirizzi syndrome?

A

A stone located within the Hartmanns pouch or cystic duct can compress the adjacent common hepatic duct, causing obstructive jaundice.

Diagnosis confirmed via MRCP and management with laparoscopic cholocystectomy.

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12
Q

What is a gallbladder empyema?

A

Occurs when the gallbladder becomes filled with pus - pt becomes unwell, septic, and presents similar to acute cholecystitis.

Diagnosed via US or CT scan.

Treatment via laparoscopic cholocystectomy.

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13
Q

What is

a) Bouveret’s syndrome

b) Gallstone ileus

A

Inflammation of the gallbladder can cause a fistula to form between the gallbladder wall and small bowel, named a cholecystoduodenal fistula.

Gallstones can pass directly into the bowel via a cholecystoduodenal fistula, causing bowel obstruction.

a) stone impacts the proximal duodenum causing a gastric outlet obstruction.

b) stone impacts the terminal ileum, causing a small bowel obstruction.

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14
Q

What is cholangitis?

A

Infection of the biliary tract, associated with high morbidity and mortality if left untreated.

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15
Q

What is the pathophysiology of cholangitis?

A

Biliary outflow obstruction results in stasis of fluid, allowing bacterial colonisation of the biliary tree to become pathological.

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16
Q

What are the causes of cholangitis?

A
  • gallstones
  • cholangiocarcinoma
  • pancreatitis

E. coli and Klebsiella species common causative organisms.

17
Q

What are the clinical features of cholangitis?

A
  • RUQ pain
  • fever
  • jaundice & pruritis

OE pyrexia, rigors, jaundice, RUQ tenderness, confusion, hypotension, tachycardia.

18
Q

What is:

a) Charcot’s triad

b) Reynold’s pentad

A

a) jaundice, fever and RUQ pain

b) jaundice, fever, RUQ pain, hypotension and confusion

19
Q

How is cholangitis differentiated from

a) biliary colic

b) cholecystitis

A

a) biliary colic is colicky RUQ pain without fever and jaundice.

b) cholecystitis is RUQ pain and fever, but no jaundice

Cholangitis has JAUNDICE

20
Q

How is cholangitis investigated?

A

FBC (leucocytosis)

LFTs showing raised ALP, GGT and bilirubin

Blood cultures before empirical abx

21
Q

How is cholangitis imaged?

A

USS of biliary tract shows bile duct dilatation.

22
Q

How is cholangitis managed?

A
  • Sepsis 6
  • endoscopic biliary decompression to remove cause of blocked biliary tree
23
Q

What is a cholangiocarcinoma?

A

Malignancy of the biliary system, most commonly an adenocarcinoma.

24
Q

What are Klatskin tumours?

A

Most common site for bile duct cancers is at the bifurcation of the right and left hepatic ducts, termed Klatskin tumours.

They are slow-growing tumours that invade locally, before spreading distally.

25
Q

What are the risk factors for cholangiocarcinomas?

A
  • primary sclerosing cholangitis
  • ulcerative colitis
  • Heptatitis
  • HIV
  • chemicals in rubber and aircraft industry
  • congenital
  • alcohol excess
  • diabetes mellitus
26
Q

What are the clinical features of cholangiocarcinomas?

A
  • aysmptomatic until late
  • jaundice
  • pruritis
  • steatorrhoea
  • non-specific abdominal pain
  • dark urine
  • weight loss
  • lethargy
27
Q

What is Courvoisier’s Law?

A

Presence of jaundice and an enlarged or palpable gallbladder should raise suspicion of pancreatic or biliary tree malignancy.

28
Q

How is cholangiocarcinoma investigated?

A
  • LFTs (elevated bilirubin, ALP, GGT)
  • tumour markers (CEA and CA19-9) elevated

CT imaging or MRI for diagnosis.

Endoscopic Retrograde CholangioPancreatography (ERCP) used to biopsy.

29
Q

How is cholangiocarcinoma managed?

A

Definitive management is complete surgical resection +/- radiotherapy.

Palliative options include stenting, surgical bypass and radiotherapy.