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AIP: Jaundice > Biliary calculi > Flashcards

Biliary calculi Flashcards

1
Q

What proportion of 1. women and 2. men may have gallstones?

A
  1. 24%
  2. 12%
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2
Q

What proportion of people with gallstones are thought to develop local infection and cholecystitis?

A

30%

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3
Q

What proportion of patients with gallstones who undergo surgery will have stones in the common bile duct?

A

12%

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4
Q

What are 3 types of gallstones and which is the commonest?

A
  1. Cholesterol
  2. Pigmented
  3. Mixed - commonest (50%)
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5
Q

What is the aetiology of most common bile duct stones and how does this vary worldwide?

A

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

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6
Q

What are the classic symptoms of gallstone disease?

A
  • colicky right upper quadrant pain, occurs postprandially
  • symptoms worst following fatty meal
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7
Q

Why are symptoms worse following a fatty meal in gallstone disease?

A

cholecystokinin levels are highests, so gallbladder contraction is maximal

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8
Q

What proportion of patients with stones within the bile duct will have at least one abnormal result on LFTs?

A

60%

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9
Q

What is a drawback of ultrasound for diagnosing gallstones?

A

it is operator dependent, may occasionally need to be repeated if negative result is at odds with the clinical picture

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10
Q

What are the 2 key investigations for initial workup of gallstones?

A
  1. Abdominal ultrasound
  2. Liver function tests
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11
Q

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?

A
  1. MRCP
  2. Intraoperative imaging

depends on skills and experience of the surgeon

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12
Q

What advantage is there of MRCP over intraoperative imaging for an ultrasound suggestive of bile duct stones?

A

intraoperative imaging is less useful for making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration

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13
Q

What are 6 types of specific gallstone/gallbladder related disease?

A
  1. Biliary colic
  2. Acute cholecystitis
  3. Cholangitis
  4. Gallstone ileus
  5. Gallbladder abscess
  6. Acalculous cholecystitis
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14
Q

What is usually the presentation of gallbladder abscess?

A
  1. usually prodromal illness and right upper quadrant pain
  2. swinging pyrexia
  3. systemically unwell
  4. generalised peritonism not present
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15
Q

What investigations should be performed to diagnose gallbladder abscess?

A

USS ± CT scanning

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16
Q

What are the management options for gallbladder abscess?

A
  • surgery - subtotal cholecystectomy may be needed if Calot’s triangle is hostile
  • in unfit patients - percutaneous drainage
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17
Q

What is the presentation of gallstone ileus?

A
  • patient may have history of previous cholecystitis and known gallstones
  • small bowel obstruction (may be intermittent)
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18
Q

What is the management of gallstone ileus?

A
  • 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
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19
Q

What is the presentation of acalculous cholecystitis?

A
  • Patients with intercurrent illness (e.g. diabetes, organ failure)
  • Patient systemically unwell
  • Gallbladder inflammation in absence of stones
  • High fever
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20
Q

What is the management of acalculous cholecystitis?

A

If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy

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21
Q

What is the approach to management of asymptomatic gallstones in the gallbladder?

A

common, no treatment needed

22
Q

What is the approach to management of stones in the common bile duct and why?

A

surgical management should be considered: there is increased risk of complications such as cholangitis or pancreatitis

23
Q

What is the treatment of choce for almost all cases of symptomatic gallstones?

A

laparoscopic cholecystectomy

24
Q

In a very frail patient, what is sometimes an option for treatment of symptomatic gallstones where the patient is unfit for laparoscopic cholecystectomy?

A

ultrasound guided cholecystostomy

25
Q

What imaging investigation is performed by some surgeons intraoperatively when performing laparoscopic cholecystectomy? What is the purpose?

A

intraoperative cholangiography - to confirm anatomy or exclude CBD stones

26
Q

What are the 2 management options if stones are found in the CBD on intraoperative cholangiography for laparoscopic cholecystectomy?

A

options are between

  1. early ERCP in day or so following surgery
  2. or immediate surgical exploration of the bile duct
27
Q

What type of immediate surgical exploration of the bile duct can be performed if there are stones in the CBD on intraoperative cholangiography?

A

transcystic surgical exploration; if fails, formal choledochotomy

28
Q

What should be done with small bile duct stones measuring <5mm?

A

may be safely left, most will past spontaneously

29
Q

What size of bile duct should not be surgically explored?

A

<8mm - too challenging

30
Q

What are 4 key risks of ERCP?

A
  1. Bleeding 0.9% (1.5% if sphincterotomy performed)
  2. Duodenal perforation 0.4%
  3. Cholangitis 1.1%
  4. Pancreatitis 1.5%
31
Q

What is the pathophysioloy of acute cholecystitis?

A

develops secondary to gallstones in 90% of patients, remaining cases are acalculous cholecystitis

32
Q

What are 4 possible aspects of the pathophysiology of acalculous cholecystitis?

A
  1. Gallbladder stasis
  2. Hypoperfusion
  3. Infection
  4. Immunosuppressed patients: secondary to Cryptosporidium or cytomegalovirus
33
Q

What is the mortality/morbidity like for acalculous cholecystitis?

A

high

34
Q

What are 4 key features of acute cholecystitis?

A
  1. Right upper quadrant pain - may radiate to right shoulder
  2. Fever and signs of systemic upset
  3. Murphy’s sign on examination: inspiratory arrest upon palpation of the right upper quadrant
  4. Liver function tests typically normal
35
Q

What are LFTs typically like in acute cholecystitis?

A

typically normal

36
Q

What may deranged LFTs in acute cholecystitis indicate?

A

Miriizi syndrome: gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct

37
Q

What is the first-line investigation of choice for acute cholecystitis?

A

ultrasound

38
Q

What investigation can be performed to diagnose acute cholecystitis if the diagnosis is unclera following ultrasound?

A

technetium-labelled cholescintigraphy aka HIDA scan - hepatobiliary iminodiacetic acid

39
Q

How does a HIDA scan work to diagnose acute cholecystitis?

A

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

40
Q

What are 2 aspects of the treatment for acute cholecystitis?

A
  1. IV antibiotics (AMG: amoxicillin, metronidazole, gentamicin)
  2. Early laparoscopic cholecystectomy within 1 week of diagnosis
    • previously was delayed for several weeks until inflammation has subsided
41
Q

What causes biliary colic?

A

gallstones passing through the biliary tree

42
Q

What are 8 risk factors for biliary colic?

A
  1. Obesity, due to enhanced cholesterol synthesis and secretion (FAT)
  2. Female - oestrogen increases activity of HMG-CoA reductase (FEMALE)
  3. Pregnancy (FERTILE)
  4. Middle-aged (FORTY)
  5. Diabetes mellitus
  6. Crohn’s disease
  7. Rapid weight loss e.g. weight reduction surgery
  8. Drugs: fibrates, COCP
43
Q

What are 2 examples of drugs which increase the risk of biliary colic?

A
  1. Fibrates
  2. COCP
44
Q

What causes biliary colic?

A

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

45
Q

What are 4 features of biliary colic?

A
  1. Colicky right upper quadrant abdominal pain
  2. Pain worse postprandially and after fatty foods
  3. Pain may radiate to right shoulder/interscpaular region
  4. Nausea and vomiting common
46
Q

What feature can gallstones in the common bile duct present with?

A

obtructive jaundice

47
Q

What is ascending cholangitis?

A

bacterial infection, typically E. coli of the biliary tree

48
Q

What type of bacteria is typically responsible for ascending cholangitis?

A

E. coli

49
Q

What is the most common predisposing factor to ascending cholangitis?

A

gallstones

50
Q

What are the ways of remembering the features of ascending cholangitis?

A

Charcot’s triad: fever, RUQ pain, jaundice

Reynold’s pentad: fever, RUQ pain, jaundice, hypotension, confusion

51
Q

What is the management of ascending cholangitis?

A

IV antibiotics, ERCP after 24-48h to relieve obstruction

AIP: Jaundice (10 decks)

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