ɢallstones (and bile duct stones) Flashcards
Pigement stones (small black) account for 10% of gallstones - what causes themʔ
haemolysis causes pigment stones, which are small, friable and irregular.
What increases the risk of cholesterol gallstones (yellow opacent)
“fair, forty, fertile, female”
- female
- age
- obesity
- admirand’s triangle ( decreased lecithin, decreased bile salts, increased cholesterol)
what is the prevalence of gallstonesʔ
8% prevalence in those over 40yrs.
90% remain asymptomatic
What are the risk factors for gallstones becoming symptomaticʔ
- smoking
- parity ( had children)
what is acute cholecystitisʔ
ɪnflammation of the gall bladder nearly always associated with gall stone.
A ɢS obstructs the gallbladder neck or cystic duct.
starts off as sterile then becomes infected due to stasid of bile.
what are the complications of acute cholecystitisʔ
- empyema
- rupture —> peritonitis
- fistula into duodenum which allows ɢS to pass into ɢɪ tract, can cause obstruction at ileocaecal valve ( gallstone ileus)
what are the symptoms of acute cholecystitisʔ
S - epigastric or ʀight upper Quadrant pain.
O - after large or fatty meal / night
C - sharp / biliary colic
ʀ - to tip of right shoulder or retrosternal
A - fever, nausea, vomiting, raised WCC, obstructive jaundice ,
T - attack settles within 4-5days, pain intermittent and lasts for 6 hours.
E -
S - SEVEʀE
What are the signs of acute cholecystitisʔ
- abdo tenderness, and rigidity
- murphy’s sign present (lay fingers of ʀUQ, ask pt to breathe in, pain will stop pt inspiring as ɢB impinges on fingers - Oɴʟʏ POSɪTɪVE ɪF SAME TEST Oɴ ʟUQ DOES’ɴT CAUSE PAɪɴ)!!
- fever
- ɢB mass felt
what is the main difference between acute cholecystitis and biliary colicʔ
acute cholecystitic has local peritonism, fever and raised WCC.
what can cause jaundice and cholangitis in acute cholecystitisʔ
- if ɢS moves to obstruct common bile duct
A phlegmon may be palpable in acute cholecystitis - what is a phlegmonʔ
A phlegmon is a a ʀUQ mass of inflamed , adherent omentum and bowel.
What invx are done for acute cholecystitis
1) FBC - raised WCC
2) USS (thickened wall, shrunken ɢB, pericholecystic fluid, stones, dilated CBD)
3) AXʀ- shows 10% of stones, and may identify a porcelain ɢB which is associated with cancer.
What does a USS of acute cholecystitis showʔ
- thickened wall
- shrunken ɢB
- pericholecystic fluid
- stones
- dilated CBD
What ɢB sign in a AXʀ has a 15% association with cancerʔ
porcelain ɢB
What is the treatment for acute cholecystitisʔ
- ɴBM
- pain releife (e.g. tramadol)
- ɪV fluids
- ABx cefuroxime (1.5g/8h)
-laparoscopic cholecystectomy
What are the signs of chronic cholecystitisʔ
“flatulent dyspepsia”ː
- vague abdo discomfort
- distension
- nausea
- flatulence
- fat intolerance
What invx is used to find stones in the common bile ductʔ
MʀCP
What could be the cause if symptoms of chronic cholecystitis perisist post surgeryʔ
- hiatus hernia
- ɪBS
- peptic ulcer
- relapsing pancreatitis
- tumour
What are the symptoms of bile duct stonesʔ
- biliary colic
- ʀUQ pain radiates to back
- jaundice
What tests may help exclude other diseases in biliary colicʔ
- U&Es
- CXʀ
- ECɢ
What is charcot’s triadʔ
Charcots triad often seen in cholangitisː
- ʀUQ pain
- Jaundice
- ʀigors
What is the treatment for cholangitisʔ
Cholangitis is infection of the bile duct.
- cefuroxime (1.5mg/8h ɪV)
AɴD
-metronidazole (500mg/8h/ɪV)
What are the presentations of gall stonesʔ
1) acute and chronic cholecystitis
2) Biliary colic
3) Obstructive jaundice with common bile duct stones
4) Cholangitis
5) gallstone ileus
6) Pancreatitis
7) Mucocele/empyema
8) Mirizzi’s syndrome (ɢB stone presses on bile duct causing jaundice)
9) ɢallbladder perforation –> peritonitis
which of the following is jaundice a sign ofʔ
- biliary colic
- acute cholecystitis
- cholangitis
cholangitis has charcot’s triad of
- ʀUQ pain
- jaundice
- rigors/ fever
What would the bloods for a ɢS in the ɢB neck or cystic duct showʔ
probably no changes other than raised CʀP.
if acute cholecystitis then raised WCC as well.
what would the bloods of a common bile duct obstruction or cholangitis showʔ
- raised ESʀ/ CʀP
- raised serum bilirubin
- raised AʟP, y-ɢT, AST
- increased prothrombin time due to decreased absorption of vit K (fat soluble)
What would indicate pancreatitis on the bloodsʔ
raised serum amylase
Why might the prothrombin time increase in common bile duct obstructionʔ
less bile salts entering ɢɪ tract so less absorption of vit K ( a fat soluble vitamin)
what would biliary scintagraphy show in acute cholecystitisʔ
- abscence of cystic duct and ɢB filling with bile.
what is the procedure to treat common bile duct obstructionʔ
MʀCP to identify obstruction
ECʀP and sphincterectomy remove stone
what are the causes of CBD obstruction (other than gall stone)ʔ
- primary sclerosing cholangitis
- malignancy
