Acute & Chronic Gallbladder Disease & Carcinoma of the Biliary Tract Flashcards
What are the common types of gallstone?
Cholesterol stones
Bile pigment stones
How do cholesterol stones form?
Cholesterol crystallisation w/i gall bladder
Due to excess cholesterol secretion/loss of bile salt
What are the risk factors for cholesterol stones?
Age Obesity, high fat diet Rapid wt loss Female, multiparity, pregnancy, OCP DM Ileal disease Liver cirrhosis
How do bile pigment stones form?
Contain calcium bilirubinate
Form independently of cholesterol stones
What are the two types of bile pigment stone?
Black
Brown
What causes black pigment gallstones?
Haemolytic conditions
What causes brown pigment gallstones?
Biliary stasis/infection
What are the Sx of biliary colic?
Severe pain that is present all the time but has periods of increased intensity Radiate to back/r shoulder Nausea/vomiting Worse after eating high fat food Often wakes patient Cessation may be spontaneous Patient systemically well
What are the Sx of acute cholecytistis?
Initial features similar to biliary colic
Severe localised RUQ pain w/ guarding/rigidity
Vomiting & systemic upset
-fever
-leukocytosis
Palpable gall bladder
Murphy’s +ve
What investigations are needed in gallstone disease?
Bloods
- FBC- look for anaemia
- CRP- raised if infection
- LFTs- can be mildly deranged
- Bilirubin- raised in ascending cholangitis or obstructive disease
- Coag- PT can be initially raised
USS
-to look for gallstones, can be difficult to visualise if patient obese
MRCP
-used if USS suggests gallstones but no gallstones are directly observed
ERCP
-endoscopy used to treat gallstones as they are found
What are the main presenting conditions caused by gallstones?
Biliary colic/acute cholecystitis Choledocholithiasis Mirizzi's syndrome Gallstone ileus Ascending cholangitis
What causes biliary colic?
Temporary obstruction of cystic duct/common bile duct by gallstone
What causes choledocholithiasis?
Stone impaction in common bile duct
Can cause biliary colic/obstructive jaundice
Predisposing to ascending cholangitis/acute pancreatitis
Describe Mirizzi’s syndrome
Gallstone impacted in cystic duct/Hartmann’s pouch –> extrinsic compression of common hepatic duct –> obstructive jaundice
Describe gallstone ileus
Due to stones blocking the small intestine
What are the possible presentations of stones in the bile ducts?
Biliary colic Acute cholecystitis Chronic cholecystitis Common bile duct obstruction Ascending cholangitis
What is Murphy’s sign?
Continuous pressure over gall bladder during inhalation will cause patient to catch breath at point of maximum inhalation
What is Courvoisier’s law?
If in the presence of jaundice the gallbladder is palpable then the jaundice is unlikely to be due to a stone
What are the most common bacterial infections found in acute cholecystitis?
E.coli
Klebisella
Streptococcus
What causes cholecystitis?
Obstruction of gall bladder emptying by gallstone leading to gall bladder distention
-2o inflammatory response
What is ascending cholangitis?
Infection of CBD, usually following cholecodolithiasis
How does ascending cholangitis present?
Charcot’s Triad:
- obstructive jaundice
- fever +/- rigors
- RUQ pain
What is the main complication of ascending cholangitis?
Severe sepsis (10% mortality)
What is chronic cholecystitis?
Repeated episodes of inflammation leads to fibrosis & thickening of gall bladder wall
- abdo pain
- discomfort/flatulence after fatty meals
What is the most common cause of CBD obstruction?
Choledocholithiasis
How does Choledocholithiasis present?
Obstructive jaundice & biliary colic
- attacks lasting hrs-days
- if obstruction not relieved can cause 2o biliary cirrhosis & liver failure
How should asymptomatic gallstones be treated?
Cholecystectomy if pt at significant risk of complications
- young pts
- comorbidities (DM, CKD)
Normally managed conservatively with reasssurance
How is biliary colic managed?
Admit, bed rest, fluids & analgesia (NBM) Elective laparoscopic cholecystectomy -hot (<72hrs) OR cold (6wks) Oral bile salts (chenodexocycholic acid) -for small, non-calcified stones
What are the potential complications of an elective laparoscopic cholecystectomy?
Bile leakage/jaundice (ductal injury)
Missed stones in CBD
Intolerance to fatty meals post-op
What are T-tubes?
Used to drain CBD/remove residual stones post-op
How is acute cholecystitis managed?
Admit, bed rest, fluids & analgesia (NBM) IV co-amoxiclav Elective laparoscopic cholecystectomy -hot (<72hrs) OR cold (6wks) Oral bile salts (chenodexocycholic acid) -for small, non-calcified stones
How is chronic cholecystitis managed?
Laparoscopic cholecystectomy w/ cholangiogram
How is obstructive jaundice due to gallstones managed?
ERCP - sphincterotomy, remove stones
-give IV vit K before
Elective laparoscopic cholecystectomy
How is ascending cholangitis managed?
Sepsis six
IV cefuroxime + metronidazole
Emergency ERCP
What are the constituents of bile?
Cholesterol Phospholipids Bile salts Water Conjugated bilirubin
What is the function of bile salts?
Break up/emulsify fats in GI tract
What is the normal flow of bile?
Bile flows into gallbladder if sphincter of Oddi closed
-becomes more concentrated
Presence of fatty acids/amino acids in duodenum releases CCK
-gall bladder contracts & sphincter opens
-bile released
What is the aetiology of carcinoma of the gall bladder?
Uncommon adenocarcinoma
Occurs in the elderly
Associated w/ longstanding gallstones
What are the sx of carcinoma of the gall bladder?
RUQ pain
N/V
Wt loss
Obstructive jaundice & palpable mass (late sign)
How does carcinoma of the gall bladder spread?
Direct invasion of liver
Lymphatic spread
What are the management options for carcinoma of the gall bladder?
Surgical
- radical cholecystectomy +/- liver resection
- if found incidentally, often presents too late
What is the prognosis for carcinoma of the gall bladder?
Survival is short
Often presents too late for surgical management
What is a cholangiocarcinoma?
Adenocarcinoma arising from epithelium of bile duct/ampulla
-often at confluence of ducts in biliary tree
How does cholangiocarcinoma present?
Painless progressive jaundice
If arise from intrahepatic ducts presents like HCC
What conditions is cholangiocarcinoma associated with?
IBD
Primary sclerosing cholangitis
What is the prognosis of cholangiocarcinoma?
Slow growing & metastasise late BUT
Often advance at presentation
Low long term survival
What are the management options for cholangiocarcinoma?
Extra-hepatic/periampullary tumours may be treated by curative resection (Whipple's) Palliative stenting (ERCP)
