Bilary pathology

Question 1

what is the medical term for the presence of solid concentrations in the gallbladder?

Answer 1

cholelithiasis

Question 2

when do gallstones cause symptoms?

Answer 2

when they get stuck in the cystic, common or pancreatic bile duct

Question 3

what are the types of gallstones?

Answer 3

pure cholesterol (10%)

Pure pigment (bile salts, 10%)

• black = associated with haemolytic disease
• brown = associated with chronic cholangitis

mixed (80%)

Question 4

what predisposes to gallstones?

Answer 4

female, fair, fertile, fat and forty

• increased age
• female
• obesity
• multiparity
• haemolytic disorders
• long term TPN

Question 5

what are the S&S of gallstones?

Answer 5

RUQ or epigastric pain

• biliary colic
• postprandial (esp fatty foods)
• tenderness on palpation
• lasts >30 mins

Dyspepsia, flatulence, bloating

Question 6

what InV are done in gallstones?

Answer 6

Abdominal US
- stones in gallbladder

LFTs
- normal

MRCP

Question 7

what are the treatment options for gallstones?

Answer 7

observation if tolerable symptoms

If symptomatic

• Analgesia
• anti-spasmodic e.g hyoscine
• cholecystectomy

Question 8

what is cholangitis?

Answer 8

an infection of the biliary tree, most commonly caused by obstruction due to gallstone deposition in the biliary tree

Question 9

what are the S&S of cholangitis?

Answer 9

RUQ pain

• typically diffuse
• NO murphy’s sign - NO NO NO
• tenderness on palpation

Jaundice

• dark urine and pale stool
• yellow skin and pruritis

Fever and Nausea

Question 10

what is Charcot’s triad?

Answer 10

used for diagnosis of cholangitis based on symptoms

• severe RUQ pain
• obstructive jaundice
• high swinging fever

Question 11

what InV are done for suspected cholangitis?

Answer 11

FBC

• leucocytosis
• thrombocytopenia

U&E’s, LFTs, creatinine

• increased urea and creatinine in severe disease
• increased bilirubin, transaminitis and Alk P
• possible hypokalaemia and hypomagnesaemia

increased CRP

Transabdominal US
- dilated bile ducts and CBD stones

MRCP

ERCP if patient cannot tolerate MRCP or intervention needed

Question 12

what is the management of cholangitis?

Answer 12

Analgesia
- morphine

IV fluids

IV ABx
- piperacillin/tazobactam OR Amox/Gent

ERCP with stone removal and drainage stent placement

Lap choledochotomy if above fails

Question 13

what is acute cholecystitis?

Answer 13

Acute inflammation of the gallbladder for which GB stone obstruction of the cystic duct is the cause in 90%.

Question 14

what are the S&S of acute cholecystitis?

Answer 14

RUQ pain

• severe and constant
• may radiate to the back or shoulder

RUQ tenderness
- Murphys sign

palpable mass

fever, N&V and anorexia

jaundice in only 10%

Question 15

what is Murphy’s sign?

Answer 15

pain on palpation of RUQ during deep inspiration that is not present on the left

Question 16

what InV are done in acute cholecysitis?

Answer 16

Abdo US

• pericholecystic fluid
• distended GB
• thickened GB wall
• Gallstones

CT/MRI abdo

• irregular thickening of GB wall
• poor contrast enhancement of GB wall - interrupted rim sign
• gas in GB lumen or wall

FBC and CRP
- increased WCC and CRP

LFTs and bilirubin
- increased bilirubin, ALP, ALT and GGT

amylase
- rule out pancreatitis

Question 17

what is the management of acute cholecysitits ?

Answer 17

analgesia
- paracetamol, diclofenac or morphine depending on pain

IV fluids

IV Abx - typically amox and Gent, add met is severe

cholecystectomy or percutaneous cholecystostomy (drain) if patient unfit for surgery

Question 18

what are the complications of acute cholecystitis?

Answer 18

empyema or abscess of GB

perforation with biliary peritonitis

cholecystenteric fistula formation