Acute and chronic gallbladder disease, carcinoma of the biliary tract Flashcards
What is bile made of?
How is it released into the duodenum?
- Bile usually conatins cholesterol, phospholipids, bile salts, water and conjugated bilirubin
- Bile salts act to break up and emulsify fats in the gut, and are enterohepatically recycled to be secreted once more into the bile
- Bile flows into the gallbladder if the sphincter of oddi is closed, where it becomes more concentrated as water is absorbed
- Presence of fatty acids or amino acids in the duodenum will lead to release of cholecystokinin (CCK), which causes the gall bladder to contract and bile to be released
What are the common types of gallstones?
How are they formed? (pathophysiology)
Cholesterol gallstones:
- Cholesterol crystallization within gall bladder bile, due to excess cholesterol secretion into the bile, or loss of bile salt content
Bile pigment stones:
- Both black and brown bile pigment gallstones contain calcium bilirubinate, and form independently of cholesterol stones
- Black pigment gallstones are associated with haemolytic conditions
- Brown pigment gallstones occur due to biliary stasis/infection, and are a common cause of recurrent bile stones following cholecystectomy
Describe the biliary system anatomy
What are risk factors for cholesterol gallstones?
(not an objective)
- Increasing age
- Obesity, high fat diet, rapid weight loss
- Female sex, multiparity (multiple children e.g. twins), pregnancy, oral contraceptive pill
- Diabetes mellitus
- Ileal disease (e.g. Crohn’s)/resection
- Disease of the ileum prevents bile salt re-absorption
- Liver cirrhosis
What is biliary colic?
Describe the symptoms of biliary colic
Pain associated with the temporary obstruction of the cystic duct or common bile duct by a stone migrating from the gall bladder
- Severe constant epigastic/RUQ pain, with a crescendo characteristic (peaks around 2 hours after eating, due to CCK peak at this time)
- May radiate to back, or right shoulder/subscapular region
- Can be associated with nausea and vomiting
- Worse upon food consumption, especially fatty foods
- Worst mid-evening, lasting until the early hours (often wakes patient)
- Cessation may be spontaneous, or terminated by opiate analgesia
- Patient will be systemically well
What is acute cholecystitis?
- An obstruction of the gall bladder emptying (due to a gallstone in 95% of cases), leading to gall bladder distension
- There is ongoing water reabsorption from the retained bile, which becomes highly concentrated, leading to a secondary inflammatory response in the wall of the gall bladder (chemical cholecystitis)
- 30% will also get a superadded infection
Describe the symptoms and signs of acute cholecystitis
Initial features are similar to biliary colic until the inflammatory component develops, leading to:
- Severe localized RUQ pain (as inflammed gallbladder touches peritoneum) with guarding and rigidity
- Vomiting & systemic upset (fever and leukocytosis)
- Palpable gall bladder - Murphy’s sign positive
- Rarely the gall bladder can become ganrenous and perforate, leading to generalized peritonitis
What is Murphy’s sign?
Continous pressure over the gall bladder whilst the patient is inhaling will cause the patient to catch their breath at the point of maximum inhalation due to pain of the inflammed gall bladder
What are the common tests used in the diagnosis of calculus biliary tract disease?
Bloods:
- WBC/Inflammatory markers raised in cholecystitis
- LFTs may be marginally deranged in cholecystitis, significant derangement and obstructive jaundice type picture in common bile duct obstruction
- Amylase to assess for pancreatitis (often mildly elevated in gallstone disease, large elevations in acut ston-related pancreatitis)
Imaging: Ultrasound
- Will show stones in gall bladder
- Thickened gall bladder of acute/chronic inflammation
- Increased diameter of the common bile duct in obstruction
Describe the natural history of a young patient with asymptomatic gallstones
- The majority of gallstones are asymptomatic and remain so during a person’s lifetime (People with asymptomatic gall stones come across problems at a rate of 1-4% per year)
- Thus, prophylactic cholecystectomy is not favoured to a “watch and wait approach”
- However, a younger patient will have more time over which to encounter problems, and so treatment may be favoured
- Small stones may be more dangerous
What is Mirizzi’s syndrome?
What does it cause?
- Gallstone impacted in the cystic duct/Hartmann’s pouch (at neck of gall bladder) causes extrinsic compression of the common hepatic duct
- This leads to obstuctive jaundice, without dilation of the cystic/common bile duct
What is ascending cholangitis?
How is it most commonly caused?
What are signs and symptoms?
- It is an infection of the bile duct
- Usually caused by bacteria ascending from its junction with the duodenum (first part of the small intestine)
- It tends to occur if the bile duct is already partially obstructed by gallstones
Signs and symptoms:
- Charcot’s triad will be present in severe disease:
- High fever (+/- rigors and chills)
- RUQ pain
- jaundice.
What is choledocohlithiasis?
What can it cause and predispose to?
- Stone impaction in the common bile duct, which can cause biliary colic if temporary, or painful obstructive jaundice if more prolonged
- This can predispose to ascending cholangitis or acute pancreatitis
What is gallstone ileus?
What may it cause?
- An uncommon condition where a large gallstone erodes through to the gall bladder lumen to create a fistula into the adjacent duodenum
- This can then produce an obstruction if it impacts in a narrow segment of bowel (usually terminal ileum)
- Characteristically on AXR there will be signs of small bowel obstruction, the gallstone may be visible and there will be air in the biliary tree (aerobilia)
Describe the management of symptomatic gallstones in the bile ducts
- Initial management is with fluids and analgesia. (keep NBM)
- Antibiotics will be administered if patients are septic. (septic 6 bundle)
- Surgery is offered to all patients suffering recurrent painful attacks, eventually.
- Emergency surgery is indicated if disease progresses, or if there is worrying gas in the gall bladder, or if perforation/GI obstruction become an issue.
