Biliary calculi Flashcards
What proportion of 1. women and 2. men may have gallstones?
- 24%
- 12%
What proportion of people with gallstones are thought to develop local infection and cholecystitis?
30%
What proportion of patients with gallstones who undergo surgery will have stones in the common bile duct?
12%
What are 3 types of gallstones and which is the commonest?
- Cholesterol
- Pigmented
- Mixed - commonest (50%)
What is the aetiology of most common bile duct stones and how does this vary worldwide?
in the West, most CBD stones are result of migration from the gallbladder but in the East a higher proportion arise in the CBD de novo
What are the classic symptoms of gallstone disease?
- colicky right upper quadrant pain, occurs postprandially
- symptoms worst following fatty meal
Why are symptoms worse following a fatty meal in gallstone disease?
cholecystokinin levels are highests, so gallbladder contraction is maximal
What proportion of patients with stones within the bile duct will have at least one abnormal result on LFTs?
60%
What is a drawback of ultrasound for diagnosing gallstones?
it is operator dependent, may occasionally need to be repeated if negative result is at odds with the clinical picture
What are the 2 key investigations for initial workup of gallstones?
- Abdominal ultrasound
- Liver function tests
If ultrasound is suggestive of stones in the bile duct, what are the 2 options for the next investigation? What does the choice depend on?
- MRCP
- Intraoperative imaging
depends on skills and experience of the surgeon
What advantage is there of MRCP over intraoperative imaging for an ultrasound suggestive of bile duct stones?
intraoperative imaging is less useful for making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration
What are 6 types of specific gallstone/gallbladder related disease?
- Biliary colic
- Acute cholecystitis
- Cholangitis
- Gallstone ileus
- Gallbladder abscess
- Acalculous cholecystitis
What is usually the presentation of gallbladder abscess?
- usually prodromal illness and right upper quadrant pain
- swinging pyrexia
- systemically unwell
- generalised peritonism not present
What investigations should be performed to diagnose gallbladder abscess?
USS ± CT scanning
What are the management options for gallbladder abscess?
- surgery - subtotal cholecystectomy may be needed if Calot’s triangle is hostile
- in unfit patients - percutaneous drainage
What is the presentation of gallstone ileus?
- patient may have history of previous cholecystitis and known gallstones
- small bowel obstruction (may be intermittent)
What is the management of gallstone ileus?
- laparotomy and removal of the gallstone from small bowel
- enterotomy must be proximal to and not at site of obstruction
- dont interfere with the fistula between GB and duodenum
What is the presentation of acalculous cholecystitis?
- Patients with intercurrent illness (e.g. diabetes, organ failure)
- Patient systemically unwell
- Gallbladder inflammation in absence of stones
- High fever
What is the management of acalculous cholecystitis?
If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy
What is the approach to management of asymptomatic gallstones in the gallbladder?
common, no treatment needed
What is the approach to management of stones in the common bile duct and why?
surgical management should be considered: there is increased risk of complications such as cholangitis or pancreatitis
What is the treatment of choce for almost all cases of symptomatic gallstones?
laparoscopic cholecystectomy
In a very frail patient, what is sometimes an option for treatment of symptomatic gallstones where the patient is unfit for laparoscopic cholecystectomy?
ultrasound guided cholecystostomy
What imaging investigation is performed by some surgeons intraoperatively when performing laparoscopic cholecystectomy? What is the purpose?
intraoperative cholangiography - to confirm anatomy or exclude CBD stones
What are the 2 management options if stones are found in the CBD on intraoperative cholangiography for laparoscopic cholecystectomy?
options are between
- early ERCP in day or so following surgery
- or immediate surgical exploration of the bile duct
What type of immediate surgical exploration of the bile duct can be performed if there are stones in the CBD on intraoperative cholangiography?
transcystic surgical exploration; if fails, formal choledochotomy
What should be done with small bile duct stones measuring <5mm?
may be safely left, most will past spontaneously
What size of bile duct should not be surgically explored?
<8mm - too challenging
What are 4 key risks of ERCP?
- Bleeding 0.9% (1.5% if sphincterotomy performed)
- Duodenal perforation 0.4%
- Cholangitis 1.1%
- Pancreatitis 1.5%
What is the pathophysioloy of acute cholecystitis?
develops secondary to gallstones in 90% of patients, remaining cases are acalculous cholecystitis
What are 4 possible aspects of the pathophysiology of acalculous cholecystitis?
- Gallbladder stasis
- Hypoperfusion
- Infection
- Immunosuppressed patients: secondary to Cryptosporidium or cytomegalovirus
What is the mortality/morbidity like for acalculous cholecystitis?
high
What are 4 key features of acute cholecystitis?
- Right upper quadrant pain - may radiate to right shoulder
- Fever and signs of systemic upset
- Murphy’s sign on examination: inspiratory arrest upon palpation of the right upper quadrant
- Liver function tests typically normal
What are LFTs typically like in acute cholecystitis?
typically normal
What may deranged LFTs in acute cholecystitis indicate?
Miriizi syndrome: gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
What is the first-line investigation of choice for acute cholecystitis?
ultrasound
What investigation can be performed to diagnose acute cholecystitis if the diagnosis is unclera following ultrasound?
technetium-labelled cholescintigraphy aka HIDA scan - hepatobiliary iminodiacetic acid
How does a HIDA scan work to diagnose acute cholecystitis?
HIDA injected and taken up selectively be hepatocytes and excreted into bile
in acute cholecystitis there is cystic duct obstruction (secondary to oedema associated with inflammation or obstructing stone) and hence gallbladder will not be visualised
What are 2 aspects of the treatment for acute cholecystitis?
- IV antibiotics (AMG: amoxicillin, metronidazole, gentamicin)
- Early laparoscopic cholecystectomy within 1 week of diagnosis
- previously was delayed for several weeks until inflammation has subsided
What causes biliary colic?
gallstones passing through the biliary tree
What are 8 risk factors for biliary colic?
- Obesity, due to enhanced cholesterol synthesis and secretion (FAT)
- Female - oestrogen increases activity of HMG-CoA reductase (FEMALE)
- Pregnancy (FERTILE)
- Middle-aged (FORTY)
- Diabetes mellitus
- Crohn’s disease
- Rapid weight loss e.g. weight reduction surgery
- Drugs: fibrates, COCP
What are 2 examples of drugs which increase the risk of biliary colic?
- Fibrates
- COCP
What causes biliary colic?
stones occur due to increased cholesterol, reduced bile salts and biliary stasis
pain occurs due to gallbladder contracting against a stone lodged in the cystic duct
What are 4 features of biliary colic?
- Colicky right upper quadrant abdominal pain
- Pain worse postprandially and after fatty foods
- Pain may radiate to right shoulder/interscpaular region
- Nausea and vomiting common
What feature can gallstones in the common bile duct present with?
obtructive jaundice
What is ascending cholangitis?
bacterial infection, typically E. coli of the biliary tree
What type of bacteria is typically responsible for ascending cholangitis?
E. coli
What is the most common predisposing factor to ascending cholangitis?
gallstones
What are the ways of remembering the features of ascending cholangitis?
Charcot’s triad: fever, RUQ pain, jaundice
Reynold’s pentad: fever, RUQ pain, jaundice, hypotension, confusion
What is the management of ascending cholangitis?
IV antibiotics, ERCP after 24-48h to relieve obstruction
