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 CONSTANT epigastric/RUQ pain w/ crescendo characteristic
Radiate to back/r shoulder
Nausea/vomiting
Worse after eating/mid-evening
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 are the common tests used to diagnose calculus biliary tract disease?

Answer 10

WBC/inflammatory markers raised
LFTs marginally deranged
Amylase
PT
Abdo USS
MRCP

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

Large gallstone erodes gall bladder lumen –> fistula into adjacent duodenum/ileum –> obstruction

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)

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 Cefuroxime Elective laparoscopic cholecystectomy -hot (<72hrs) OR cold (6wks) Oral bile salts (chenodexocycholic acid) -for small, non-calcified stones ```

Question 32

What are the most commonly cultured organisms in acute cholecystitis?

Answer 32

E. coli Klebsiella Streptococcus

Question 33

How is chronic cholecystitis managed?

Answer 33

Laparoscopic cholecystectomy w/ cholangiogram

Question 34

How is obstructive jaundice due to gallstones managed?

Answer 34

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

Question 35

How is ascending cholangitis managed?

Answer 35

Sepsis six IV cefuroxime + metronidazole Emergency ERCP

Question 36

What are the constituents of bile?

Answer 36

``` Cholesterol Phospholipids Bile salts Water Conjugated bilirubin ```

Question 37

What is the function of bile salts?

Answer 37

Break up/emulsify fats in GI tract

Question 38

What is the normal flow of bile?

Answer 38

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 39

What is the aetiology of carcinoma of the gall bladder?

Answer 39

Uncommon adenocarcinoma Occurs in the elderly Associated w/ longstanding gallstones

Question 40

What are the sx of carcinoma of the gall bladder?

Answer 40

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

Question 41

How does carcinoma of the gall bladder spread?

Answer 41

Direct invasion of liver | Lymphatic spread

Question 42

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

Answer 42

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

Question 43

What is the prognosis for carcinoma of the gall bladder?

Answer 43

Survival is short | Often presents too late for surgical management

Question 44

What is a cholangiocarcinoma?

Answer 44

Adenocarcinoma arising from epithelium of bile duct/ampulla | -often at confluence of ducts in biliary tree

Question 45

How does cholangiocarcinoma present?

Answer 45

Painless progressive jaundice | If arise from intrahepatic ducts presents like HCC

Question 46

What conditions is cholangiocarcinoma associated with?

Answer 46

IBD | 1o sclerosing cholangitis

Question 47

What is the prognosis of cholangiocarcinoma?

Answer 47

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

Question 48

What are the management options for cholangiocarcinoma?

Answer 48

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