ɢallstones (and bile duct stones)

Question 1

Pigement stones (small black) account for 10% of gallstones - what causes themʔ

Answer 1

haemolysis causes pigment stones, which are small, friable and irregular.

Question 2

What increases the risk of cholesterol gallstones (yellow opacent)

Answer 2

“fair, forty, fertile, female”

• female
• age
• obesity
• admirand’s triangle ( decreased lecithin, decreased bile salts, increased cholesterol)

Question 3

what is the prevalence of gallstonesʔ

Answer 3

8% prevalence in those over 40yrs.

90% remain asymptomatic

Question 4

What are the risk factors for gallstones becoming symptomaticʔ

Answer 4

• smoking

- parity ( had children)

Question 5

what is acute cholecystitisʔ

Answer 5

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.

Question 6

what are the complications of acute cholecystitisʔ

Answer 6

• empyema
• rupture —> peritonitis
• fistula into duodenum which allows ɢS to pass into ɢɪ tract, can cause obstruction at ileocaecal valve ( gallstone ileus)

Question 7

what are the symptoms of acute cholecystitisʔ

Answer 7

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

Question 8

What are the signs of acute cholecystitisʔ

Answer 8

• 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

Question 9

what is the main difference between acute cholecystitis and biliary colicʔ

Answer 9

acute cholecystitic has local peritonism, fever and raised WCC.

Question 10

what can cause jaundice and cholangitis in acute cholecystitisʔ

Answer 10

• if ɢS moves to obstruct common bile duct

Question 11

A phlegmon may be palpable in acute cholecystitis - what is a phlegmonʔ

Answer 11

A phlegmon is a a ʀUQ mass of inflamed , adherent omentum and bowel.

Question 12

What invx are done for acute cholecystitis

Answer 12

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.

Question 13

What does a USS of acute cholecystitis showʔ

Answer 13

• thickened wall
• shrunken ɢB
• pericholecystic fluid
• stones
• dilated CBD

Question 14

What ɢB sign in a AXʀ has a 15% association with cancerʔ

Answer 14

porcelain ɢB

Question 15

What is the treatment for acute cholecystitisʔ

Answer 15

• ɴBM
• pain releife (e.g. tramadol)
• ɪV fluids
• ABx cefuroxime (1.5g/8h)

-laparoscopic cholecystectomy

Question 16

What are the signs of chronic cholecystitisʔ

Answer 16

“flatulent dyspepsia”ː

• vague abdo discomfort
• distension
• nausea
• flatulence
• fat intolerance

Question 17

What invx is used to find stones in the common bile ductʔ

Answer 17

MʀCP

Question 18

What could be the cause if symptoms of chronic cholecystitis perisist post surgeryʔ

Answer 18

• hiatus hernia
• ɪBS
• peptic ulcer
• relapsing pancreatitis
• tumour

Question 19

What are the symptoms of bile duct stonesʔ

Answer 19

• biliary colic
• ʀUQ pain radiates to back
• jaundice

Question 20

What tests may help exclude other diseases in biliary colicʔ

Answer 20

• U&Es
• CXʀ
• ECɢ

Question 21

What is charcot’s triadʔ

Answer 21

Charcots triad often seen in cholangitisː

• ʀUQ pain
• Jaundice
• ʀigors

Question 22

What is the treatment for cholangitisʔ

Answer 22

Cholangitis is infection of the bile duct.
- cefuroxime (1.5mg/8h ɪV)
AɴD
-metronidazole (500mg/8h/ɪV)

Question 23

What are the presentations of gall stonesʔ

Answer 23

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

Question 24

which of the following is jaundice a sign ofʔ

• biliary colic
• acute cholecystitis
• cholangitis

Answer 24

cholangitis has charcot’s triad of

• ʀUQ pain
• jaundice
• rigors/ fever

Question 25

What would the bloods for a ɢS in the ɢB neck or cystic duct showʔ

Answer 25

probably no changes other than raised CʀP.

if acute cholecystitis then raised WCC as well.

Question 26

what would the bloods of a common bile duct obstruction or cholangitis showʔ

Answer 26

• raised ESʀ/ CʀP
• raised serum bilirubin
• raised AʟP, y-ɢT, AST
• increased prothrombin time due to decreased absorption of vit K (fat soluble)

Question 27

What would indicate pancreatitis on the bloodsʔ

Answer 27

raised serum amylase

Question 28

Why might the prothrombin time increase in common bile duct obstructionʔ

Answer 28

less bile salts entering ɢɪ tract so less absorption of vit K ( a fat soluble vitamin)

Question 29

what would biliary scintagraphy show in acute cholecystitisʔ

Answer 29

• abscence of cystic duct and ɢB filling with bile.

Question 30

what is the procedure to treat common bile duct obstructionʔ

Answer 30

MʀCP to identify obstruction

ECʀP and sphincterectomy remove stone

Question 31

what are the causes of CBD obstruction (other than gall stone)ʔ

Answer 31

• primary sclerosing cholangitis

- malignancy