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
Form when bile becomes supersaturated with cholesterol

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.

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:
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.
Oral contraception - particularly in young women.

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 necrosis and ischaemia of the mucosal wall.

May also present with:
Chronic Cholecystitis
Obstructive Jaundice
Pancreatitis

Note:

• *Cholecystitis** = inflammation of the gallbladder commonly due a stone blocking the cystic duct.
• *Cholangitis** = Infection of the biliary tree which can ascend and is a medical emergency

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.
Lasts <6 hours.
May be associated nausea or vomiting.

Cholecystits:
Continuous RUQ or epigastric pain
Associated vomiting.

Different signs and symptoms to biliary colic:
GB mass.
Fever. (Raised WBC)
Peritonism (abdominal pain, abdominal tenderness and abdominal guarding)
Murphys sign positive:

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 cholecystitis
LFTs: Raised ALP
Lipase: To rule out pancreatitis

Ultrasound to find the stone. (90% stones)

Endoscopic retrograde cholangiopancreatography (ERCP)
Can be used to diagnose and remove stones.

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

Question 6

Describe the symptoms of cholangitis?

Answer 6

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 calculus of the biliary tract be managed?

Answer 7

Non surgical:
Analgesia (morphine)
If antibiotics are indicated they should initially be IV.

Surgical:
Cholecystectomy Laproscopic usually.
May be open in emergencies.

Cholangitis: If septic.
Septic 6: (BUFALO)
IN: O₂, Fluids, Broad spec antibiotics
OUT: Lactate, Blood 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.

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.

Typically elderly female patients

Small bowel obstruction with air in the Biliary Tree on X-Ray

Question 11

What are the most common causative organisms in acute cholecyctitis?

Answer 11

E.coli
Klebsiella
Streptococcus

Question 12

Define Cholecystitis

Answer 12

Inflammation of the gallbladder

Question 13

Choledocholithiasis

Answer 13

Gallstones in the common bile duct
May be asymptomatic

Question 14

What is Cholangitis

Answer 14

Infection of the biliary tree

(look for Charcots triad)

Question 15

What is Murphys Sign?

Answer 15

Place to fingers on the patients RUQ and ask them to breath in, as they breath in it will cause your fingers to impinge on the gallbladder and cause pain.
Must be normal in the LUQ for the test to be +ve.

Question 16

Mx of Biliary Colic

Answer 16

Analgesia

Fluids and electrolytes

Elective Cholesystectomy

Question 17

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

Answer 17

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

Question 18

What are risk factors for carcinoma of the gallbladder?

Answer 18

Gallstones

Extensive gallbladder calcification - porcelain gall bladder

Question 19

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

Answer 19

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