Bile Stone Disease

Question 1

Gold standard method of investigation of bile stone disease

Answer 1

US

Question 2

Daily production of bile in adults

Answer 2

800ml

Question 3

Group risks (5Fs)

Answer 3

1. Fat
2. Female
3. Forty
4. Fertile
5. Fair

Question 4

5 complications of of GBD

Answer 4

1. Acute cholecystitis (M/C): block of outflow of cystic duct.
2. Choledecholithiasis: block of common bile duct (sphincter oddi contracts and traps GS)
3. Acute pancreatitis (2nd M/C): cause of MOF -> pts can die.
4. Mechanical Jaundice (increase temperature e.g. 39.3 degree Celsius).
   - White/Grey stool due to absence of bile
   - Rectal examination
   - Stone blocks liver outflow of bile
   - Dangerous (infection -> acute purulent cholangitis)
5. Acute purulent cholangitis

Question 5

Acute Cholecystitis

Answer 5

• Abturated biliary tree -> purulent inflammatory process.
• Diagnostic method (US)
• Pt can die
• Good source of infection

Question 6

3 types/stages of Acute Cholecystitis

Answer 6

1. Acute Catarrhal (inflammation in mucus layer)
2. Acute phlegmonous (inflammation in all layers of GB -> GB invaded with bacteria (Pus)
3. Acute gangrenous (necrosis of walls of GB)

Question 7

5 complications of acute cholecystitis

Answer 7

1. Paravesicular infiltrate (covers purulent factor from abdomen)
   a. Resolution
   b. Abscess formation
2. Paravesicular abscess:
   - cannot resolute
   - Big -> rupture
3. Diffuse Peritonitis
4. Mucocele
   - Pure water (mucus) filled
   - Sac with bile, separate from biliary tree, no infection.
   - Can be a good condition for infection
5. Empyema
   - Laproscopic cholecystectomy

Question 8

Clinical Picture (2 syndromes)

Answer 8

• Asymptomatic (most cases)
• Presence of complications (symptoms appear)

1. Local abdominal sign (after meal)
   - RUQ pain
2. Intoxication signs (increase temperature e.g. 37-38 degree Celsius)

Question 9

Acute cholecystitis (Lab results)

Answer 9

Clinical blood analysis:
- Leukocytosis
- Erythrocytes (+)
- CRP (+)
- ESR (increased)

Biochemical:
- Increased direct bilirubin (GS can cause stone to block other duct)
- Concentration of amylase

Question 10

Acute cholecystitis (diagnosis)

Answer 10

• US investigation
• Findings:
  a. Enlarged GB with stones (Block of GB neck)
  b. Thickening of walls of GB (due to edema)
  c. Paravesicular fluid (fluid that lie near GB)

Question 11

Treatment of Acute cholecystitis

Answer 11

1. Conservatively:
   - Antibiotics (Amoxicillin/Clavulanate +/- Metronidazole), 24hr fasting, IV fluid, analgesics for pain
2. Surgery:
   - Cholecystectomy (laparoscopically)

Question 12

Acute Purulent cholangitis

Answer 12

• Diagnostic methods: US
• Findings:
  a. Stone in CBD
  b. CBD size enlargement
  c. Widening of biliary tree -> sign of mechanical jaundice

Question 13

Treatment of Acute Purulent Cholangitis

Answer 13

Percutaneous Cholecystostomy - drain infection (part of biliary tree) -> Mechanical Jaundice disappears (next day)

Question 14

Causes of Mechanical Jaundice

Answer 14

1. GBD (M/C)
2. Tumor (>43 y/o)

Question 15

Investigation methods for acute purulent cholangitis

Answer 15

1. US
2. ERCP
3. Gastroesophagoduodenoscopy
4. EPST

Question 16

Charcot Triad (sign of Acute purulent cholangitis)

Answer 16

1. Fever
2. Mechanical Jaundice
3. Pain in RUQ

Question 17

Renauld’s Pentad (sign of acute purulent cholangitis)

Answer 17

1. Altered Mental status
2. Hypotension
3. Charcot’s triad
   - Fever
   - Mechanical Jaundice
   - Pain in RUQ

• Old women
• Confused state

Question 18

ERCP

Answer 18

Endoscopic Retrograde Cholangiopancreatography

• X-ray machine
• Endoscopic equipment

Question 19

Gastroesophagoduodenoscopy

Answer 19

• Endoscopy
• Find papilla Fateri -> inside CBD -> inject contrast -> x-ray film
• Stone (+) -> remove during endoscopy

Question 20

EPST

Answer 20

Endoscopic Papilla Sphincterotomy
(Treatment: mechanical jaundice due to GSD)
- Cute sphincter oddi (unable to contract) -> so it relaxes -> hole is big now -> stone can be removed