Acute & Chronic Gallbladder Disease & Carcinoma of the Biliary Tract

Question 1

What are the common types of gallstone?

Answer 1

Cholesterol stones

Bile pigment stones

Question 2

How do cholesterol stones form?

Answer 2

Cholesterol crystallisation w/i gall bladder

Due to excess cholesterol secretion/loss of bile salt

Question 3

What are the risk factors for cholesterol stones?

Answer 3

Age
Obesity, high fat diet
Rapid wt loss
Female, multiparity, pregnancy, OCP
DM
Ileal disease
Liver cirrhosis

Question 4

How do bile pigment stones form?

Answer 4

Contain calcium bilirubinate

Form independently of cholesterol stones

Question 5

What are the two types of bile pigment stone?

Answer 5

Black

Brown

Question 6

What causes black pigment gallstones?

Answer 6

Haemolytic conditions

Question 7

What causes brown pigment gallstones?

Answer 7

Biliary stasis/infection

Question 8

What are the Sx of biliary colic?

Answer 8

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

Question 9

What are the Sx of acute cholecytistis?

Answer 9

Initial features similar to biliary colic
Severe localised RUQ pain w/ guarding/rigidity
Vomiting & systemic upset
-fever
-leukocytosis
Palpable gall bladder
Murphy’s +ve

Question 10

What investigations are needed in gallstone disease?

Answer 10

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

Question 11

What are the main presenting conditions caused by gallstones?

Answer 11

Biliary colic/acute cholecystitis
Choledocholithiasis
Mirizzi's syndrome
Gallstone ileus
Ascending cholangitis

Question 12

What causes biliary colic?

Answer 12

Temporary obstruction of cystic duct/common bile duct by gallstone

Question 13

What causes choledocholithiasis?

Answer 13

Stone impaction in common bile duct
Can cause biliary colic/obstructive jaundice
Predisposing to ascending cholangitis/acute pancreatitis

Question 14

Describe Mirizzi’s syndrome

Answer 14

Gallstone impacted in cystic duct/Hartmann’s pouch –> extrinsic compression of common hepatic duct –> obstructive jaundice

Question 15

Describe gallstone ileus

Answer 15

Due to stones blocking the small intestine

Question 16

What are the possible presentations of stones in the bile ducts?

Answer 16

Biliary colic
Acute cholecystitis
Chronic cholecystitis
Common bile duct obstruction
Ascending cholangitis

Question 17

What is Murphy’s sign?

Answer 17

Continuous pressure over gall bladder during inhalation will cause patient to catch breath at point of maximum inhalation

Question 18

What is Courvoisier’s law?

Answer 18

If in the presence of jaundice the gallbladder is palpable then the jaundice is unlikely to be due to a stone

Question 19

What are the most common bacterial infections found in acute cholecystitis?

Answer 19

E.coli
Klebisella
Streptococcus

Question 20

What causes cholecystitis?

Answer 20

Obstruction of gall bladder emptying by gallstone leading to gall bladder distention
-2o inflammatory response

Question 21

What is ascending cholangitis?

Answer 21

Infection of CBD, usually following cholecodolithiasis

Question 22

How does ascending cholangitis present?

Answer 22

Charcot’s Triad:

• obstructive jaundice
• fever +/- rigors
• RUQ pain

Question 23

What is the main complication of ascending cholangitis?

Answer 23

Severe sepsis (10% mortality)

Question 24

What is chronic cholecystitis?

Answer 24

Repeated episodes of inflammation leads to fibrosis & thickening of gall bladder wall

• abdo pain
• discomfort/flatulence after fatty meals

Question 25

What is the most common cause of CBD obstruction?

Answer 25

Choledocholithiasis

Question 26

How does Choledocholithiasis present?

Answer 26

Obstructive jaundice & biliary colic

• attacks lasting hrs-days
• if obstruction not relieved can cause 2o biliary cirrhosis & liver failure

Question 27

How should asymptomatic gallstones be treated?

Answer 27

Cholecystectomy if pt at significant risk of complications

• young pts
• comorbidities (DM, CKD)

Normally managed conservatively with reasssurance

Question 28

How is biliary colic managed?

Answer 28

Admit, bed rest, fluids & analgesia (NBM)
Elective laparoscopic cholecystectomy
   -hot (<72hrs) OR cold (6wks)
Oral bile salts (chenodexocycholic acid)
   -for small, non-calcified stones

Question 29

What are the potential complications of an elective laparoscopic cholecystectomy?

Answer 29

Bile leakage/jaundice (ductal injury)
Missed stones in CBD
Intolerance to fatty meals post-op

Question 30

What are T-tubes?

Answer 30

Used to drain CBD/remove residual stones post-op

Question 31

How is acute cholecystitis managed?

Answer 31

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

Question 32

How is chronic cholecystitis managed?

Answer 32

Laparoscopic cholecystectomy w/ cholangiogram

Question 33

How is obstructive jaundice due to gallstones managed?

Answer 33

ERCP - sphincterotomy, remove stones
-give IV vit K before
Elective laparoscopic cholecystectomy

Question 34

How is ascending cholangitis managed?

Answer 34

Sepsis six
IV cefuroxime + metronidazole
Emergency ERCP

Question 35

What are the constituents of bile?

Answer 35

Cholesterol
Phospholipids
Bile salts
Water
Conjugated bilirubin

Question 36

What is the function of bile salts?

Answer 36

Break up/emulsify fats in GI tract

Question 37

What is the normal flow of bile?

Answer 37

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

Question 38

What is the aetiology of carcinoma of the gall bladder?

Answer 38

Uncommon adenocarcinoma
Occurs in the elderly
Associated w/ longstanding gallstones

Question 39

What are the sx of carcinoma of the gall bladder?

Answer 39

RUQ pain
N/V
Wt loss
Obstructive jaundice & palpable mass (late sign)

Question 40

How does carcinoma of the gall bladder spread?

Answer 40

Direct invasion of liver

Lymphatic spread

Question 41

What are the management options for carcinoma of the gall bladder?

Answer 41

Surgical

• radical cholecystectomy +/- liver resection
• if found incidentally, often presents too late

Question 42

What is the prognosis for carcinoma of the gall bladder?

Answer 42

Survival is short

Often presents too late for surgical management

Question 43

What is a cholangiocarcinoma?

Answer 43

Adenocarcinoma arising from epithelium of bile duct/ampulla

-often at confluence of ducts in biliary tree

Question 44

How does cholangiocarcinoma present?

Answer 44

Painless progressive jaundice

If arise from intrahepatic ducts presents like HCC

Question 45

What conditions is cholangiocarcinoma associated with?

Answer 45

IBD

Primary sclerosing cholangitis

Question 46

What is the prognosis of cholangiocarcinoma?

Answer 46

Slow growing & metastasise late BUT
Often advance at presentation
Low long term survival

Question 47

What are the management options for cholangiocarcinoma?

Answer 47

Extra-hepatic/periampullary tumours may be treated by curative resection (Whipple's)
Palliative stenting (ERCP)