Biliary Flashcards
Should asymptomatic stones be treated?
if in gallbladder - no treatment as unlikely to cause symptoms
in common bile duct -> increased risk of complications so may need treatment
Gallstones
- what gender does it affect more?
- how common are gallstones?
- why do they develop?
Under 40 years old - female more common 3:1
Elderly – equal sex ratio
50/60 y/o – 1 in 3 has gall stones
Crystals/stones develop due to imbalance of main constituents: bile salts, cholesterol and phospholipids
5 F’s = fat, forty, female, fertile, FH
Gallstones risk factors
Increased cholesterol secretion
- Obesity
- Old age
- Female gender
- Pregnancy
- Rapid weight loss
Impaired gallbladder emptying
- Pregnancy
- Gallbladder stasis
- Fasting
- Total parenteral nutrition
- Spinal cord injury
Decreased bile salt secretion
- Pregnancy
FH, COCP, low dibre diet, terminal ileal disease
Gallstones presentation
largely asymptomatic (90%)
symptomatic
- biliary colic
- acute cholecystitis
- empyema/mucocoele
Stuck at ampulla of Vater
- common bile duct stones
- acute cholangitis
gallstone in ileus -> obstruction
Biliary colic
- what causes it?
- presentation?
- diagnosis?
- treatment?
Present if have transient obstruction
intermittent episode of epigastric/RUQ pain
- may radiate to lower scapula
- sudden intense episodes of pain, which build up then subsides (2 hours)
- may mimic intrathoracic disease, oesophagitis, MI or dissecting aortic aneurysm
- often brought on by fatty foods
NO FEVER AND NO SYSTEMIC INFLAMMATORY RESPONSE
Diagnosis
- WCC (normal - excludes infections - cholangitis)
- LFT normal - excludes obstruction to CBD
- amylase normal
- US gallstones seen
Treatment = laparoscopic cholecystectomy
Biliary colic - what is pain like?
intermittent episode of epigastric/RUQ pain
- may radiate to lower scapula
- sudden intense episodes of pain, which build up then subsides (2 hours)
Biliary colic - what does pain mimic?
may mimic intrathoracic disease, oesophagitis, MI or dissecting aortic aneurysm
Biliary colic - what may bring the pain on?
often brought on by fatty foods
Biliary colic diagnosis
US gallstones seen
- WCC (normal - excludes infections - cholangitis)
- LFT normal - excludes obstruction to CBD
- amylase normal
Acute cholecystitis
- what causes it?
- presentation?
- diagnosis?
- treatment?
Pathophysiology
- Acute gallbladder inflammation
- obstruction of gallbladder neck or cystic duct by gall stone
- Gallbladder mucosal damage → releases phospholipase → converts biliary lecithin to lysolecithin (mucosal toxin)
Clinical features
- Pain – RUQ, epigastrium, right shoulder tip region; Severe and prolonged; Maximally tender RUQ +/- biliary colic symptoms
- Associated systemic upset: anorexia, nausea, vomiting, fever
- Jaundice (<10%)
Exam
- RUQ peritonism
- Tenderness +/- guarding
- Rigidity worse on inspiration (Murphy’s sign)
- Place 2 fingers over RUQ – ask patient to breathe in. Causes pain and arrest of inspiration as inflamed gall bladder impinges on fingers
- Only +ve – if same test of LUQ causes no pain
- Gall bladder mass (30%)
Inflammatory component present -> local peritonism, fever, increased WCC
Investigations
- Peripheral blood leucocytosis (increased WCC)
- Minor increase in transaminases and amylase
- Amylase → acute pancreatitis (may be complication of gallstones)
- Xray abdomen & chest
Radio-opaque gallstones
Rare – intrabiliary gas due to fistulation of gallstone in intestine
- US - Detect gallstones and gallbladder thickening due to cholecystitis
Management
Medical
- Bed rest
- Nil by mouth (for US scan then feed unless listed for surgery)
- Antibiotics - Cephalosporin (e.g. cefuroxime) or piperacillin/tazobactam
- IV fluids
- Analgesia = Moderate pain → NSAIDs / severe →opiates
Surgical
- Urgent if progresses in spite of medical treatment or have complications (empyema or perforation)
- Laparoscopic cholecystectomy = treatment of choice if fit for GA
- Open surgery required if gall bladder perforates
Early
- Definitive treatment same episode
- Avoid complications
- Increased risk of infection/wound complications
Late
- Further elective admission (>6 weeks); Risk of recurrent problems
Stuck at ampulla of Vater
- presentation
- investigations
Obstructive jaundice
Presentation like biliary colic – epigastric pain, nausea, vomiting, (intermittent) BUT HAS jaundice
Investigations
- LFTs (elevated bilirubin, ALP)
- Coagulation (prothrombin time)
- Reduced absorption of fat soluble vitamins (A/D/E/K)
If suspicious of gall stones: USS +/- MRCP +/- ERCP
Acute cholangitis
Inflammation of bile duct
Charcot’s triad – RUQ pain, fever (+/- rigors), jaundice
Findings: Severely septic and unwell
- SIRS/septic (+/- shocked), icteric
Management
- Resuscitate – treat sepsis (IV fluids, antibiotics – typically Tazocin, close monitoring (hepato-renal syndrome)
- Investigate – WBC/coagulation screen, LFTs/amylase, blood culture, US
Treatment
ERCP – sphincterotomy +/- stent
- CBD cleared in 80%
- 5-10% complication rate: bleeding, cholangitis, pancreatitis, perforation
Cholecystectomy +/- exploration of CBD
Gallstone ileus
gallstone enters gut and causes obstruction
Biliary disease DD
Peptic ulcer disease
GORD
Acute pancreatitis
Acute appendicitis
Renal pathology
- Renal/ureteric colic (right sided)
- Pyelonephritis
IBS
Gallstones treatment
Treat only symptomatic patients
Conservative – low fat diet
Medical
- Oral dissolution therapy (ursodeoxycholic acid)
- Lithotripsy
Surgical
- Laparoscopic
- decreased post-op pain, earlier discharge, earlier return to function, improved comsesis
BUT increased risk of bile duct injury
- Cholecystectomy
