Acute and Chronic Gallbladder disease

Question 1

List the common types of gallstones which may form and why they form?

Answer 1

Bile contains cholesterol, bile pigments (from broken-down haemoglobin) and phospholipids. If the concentrations of these vary, different kinds of stones may be formed.

Cholesterol stones (most common 80% in UK)
Large, usually solitary and radiolucent

Black Pigment Stones:
Small, irregular, radiolucent and easily broken up.
Major risk factors include anything causing haemolysis and cirrhosis.

Mixed stones (brown pigment stones) are faceted and are comprised of calcium salts, pigment and cholesterol. Caused by biliary stasis.

Question 2

Describe the typical patient that will suffer from gallstones?

Answer 2

5F’s Fair, Fat, Fertile, Forty y/o, Female

Other RF’s:
Haemolytic conditions
Increasing age.
Positive family history.
Sudden weight loss - eg, after obesity surgery.
Loss of bile salts - eg, ileal resection, terminal ileitis.
Diabetes - as part of the metabolic syndrome.
COP, multiparty, pregnancy

Question 3

What conditions can gallstones cause?

Answer 3

70% are assymptomatic.

Most common presentations:
Biliary Colic: Gallstone impacting in the cystic duct or ampulla of vater (controlled by the sphincter of oddi).

Acute Cholecystitis: caused by distension of the GB with subsequent infection which can lead to ischaemia of the mucosal wall.

May also present with:
Chronic cholecystitis
Obstructive jaundice
Pancreatitis
Empyema
Chloledocholithiasis
Ascending cholangitis

Question 4

Compare the signs and symptoms of a patient with biliary colic and cholecystitis?

Answer 4

Biliary Colic:
RUQ or epigastric radiating to the back.
Not truly colicy in nature lasts 15mins -24hrs.
May be associated nausea or vomiting.

Cholecystits: 
Continuous RUQ or epigastric pain
May be associated with nausea and vomiting. 
Localised pain
GB mass.
Fever. (Raised WBC)
May have local peritonism (abdominal pain, abdominal tenderness and abdominal guarding)
Murphys sign positive

(Must be normal in the LUQ for the test to be +ve. )

Question 5

What investigations will you do to diagnose calculus biliary tract disease (e.g. biliary colic, cholecystitis)?

Answer 5

Bloods:
FBC: WBC raised in acute cholecystitis
LFTs: Raised ALP in obstruction
Lipase/Amylase: To rule out pancreatitis
Prothrombin time: pre intervention (likely increased)

Ultrasound to find the stones or dilation of the CBD.
MRCP can be used to identify stones if US is inconclusive.

Endoscopic retrograde cholangiopancreatography (ERCP) can be used to diagnose and remove stones. (rarely used diagnostically as there are relatively high risk of complications aka 10% get pancreatitis)

CXR, ECG, Urinalysis to exclude other causes:
Aortic dissection.
AAA
Kidney dysfunction.
Renal caliculi.

Question 6

Describe the aetiology and symptoms of cholangitis?

Answer 6

Infection in the biliary tree usually precipitated by a gallstone causing an obstruction.

Charcot’s Triad:
RUQ pain.
Fever.
Jaundice.

It is graded on severity 1,2,3.

Grade 3 severity is classified as choalngitis with dysfunction of one of the following systems: cardiovascular, neurological, respiratory, renal, hepatic and/or haematological.

10-20% will also present with hypotension due to septic shock.

Note: Peritonism is unusual therefore you should consider an alternative diagnose if it is present.

Question 7

How should gallstone disease be managed?

Answer 7

Non surgical:
Analgesia (morphine) for biliary colic with a view to an elective ERCP/lap chole.
If cholecystitis broad spectrum IV antibiotics (cefuroxime IV)

ERCP:
Biliary sphincterectomy and stone extraction if stone is in CBD

Surgical:
Cholecystectomy usually laparoscopic.
May be open in emergencies.
Within 72h if biliary colic or cholecystitis, Usually elective if ascending cholangitis

Cholangitis: If septic.
Septic 6:
IN: O2, Fluids, Broad spec antibiotics
OUT: Lactate, Cultures, Urine output

Biliary drainage is also needed usually: endoscopic biliary drainage.

Question 8

What is a T-Tube and when is it used?

Answer 8

A T-tube is a t shaped rubber tube put in the common bile duct during surgery to help it to drain.

Contrast Dye can also be injected through the tube and x-rays are taken to detect any other stones or strictures.

Question 9

What is Courvoisier’s sign?

Answer 9

A non tender palpable gallbladder with jaundice is not due to gallstones.

More likely malignancy of: head of pancreas or gallbladder.

Pancreas causes full obstruction + gallbladder not inflamed so able to distend/ not painful.

Question 10

What is gallstone ileus?

Answer 10

Bowel obstruction caused by impaction of gallstones in the bowel.

Gallstones have to be >2.5cm to cause a problem and they are most commonly lodged in the ileum.

Triad of radiological signs are:
Small bowel obstruction
Gallstone visible on xray
Pneumobilia (Air in the biliary tree)

Question 11

What is percutaneous transhepatic cholangiography?

Answer 11

A specialist imaging which involves transhepatic insertion of a needle into a bile duct, followed by injection of contrast material to opacify the bile ducts. Following this Xrays are taken.

PTC is usually performed for evaluation of patients who are found to have biliary duct dilation on ultrasonography or other imaging tests and who are not candidates for endoscopic retrograde cholangiopancreatography (ERCP). Aka have altered anatomy due to previous surgery or have previously had unsuccessful ERCP.

Question 12

Describe the presentation of carcinoma of the gallbladder, bile duct and ampulla of vater?

Answer 12

Gallbladder cancer, cholangiocarcinoma (bile duct) and ampullary carcinoma are all rare malignancies which present late with the following symptoms:

• Jaundice
• Pruritis
• RUQ pain
• Weight loss and anorexia
• N+V

Question 13

Describe the general prognosis of gallbladder, cholangiocarcinoma and ampullary carcinoma?

Answer 13

Gallbladder and cholangiocarcinoma both have poor prognoses due to them presenting late.

Cholangiocarcinoma is slow growing and metastasis late.

Primary ampullary carcinomas have a better prognosis than periampullary carcinomas (e.g. pancreatic) with a 5 year survival rate of 30-50% in patients with limited lymph node involvement. Main treatment is resection.

Question 14

Name the condition most likely responsible for each of these presentations:

1. RUQ pain, Jaundice
2. Localised RUQ pain, fever, N+V, guarding, murpheys sign
3. Generalised RUQ pain post meals, N+V
4. RUQ pain, rigors, jaundice, fever

Answer 14

1. Choledocholithiases
2. Acute cholecystitis
3. Biliary colic
4. Ascending cholangitis

Question 15

What is Mirizzi syndrome?

Answer 15

Gallstone impacting in the cytic duct causing extrinsic compression of the common hepatic duct.

Question 16

What are the USS findings in the following conditions:

1. Choledocholithiases
2. Acute cholecystitis
3. Biliary colic
4. Ascending cholangitis
5. Mirizzi syndrome

Answer 16

1. Distended common hepatic duct
2. Thickened wall of gallbladder + stones
3. Stones in gallbladder
4. Distended common hepatic duct
5. Jaundice without dilation of the common hepatic duct

Question 17

Describe the treatment of

1. cholangiocarcinoma
2. carcinoma of the gall bladder
3. Peri-ampullary tumours

Answer 17

1. Whipples procedure if extra-hepatic. Palliative stenting if late presentation
2. Radical chloecystectomy +/- liver resection.
3. Whipples procedure. Palliative stenting if late presentation

Question 18

Risk factors for

1. Cholangiocarcinoma
2. Carcinoma of the gall bladder

Answer 18

1. Primary sclerosing cholangitis

2. Long standing gallstones