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yr 3 GI > biliary colic > Flashcards

biliary colic Flashcards

1
Q

def of gallstones

A

stone formation in the gallbladder

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2
Q

def of biliary colic n

A

severe abdominal pain from obstruction of the cystic duct or CBD, most commonly by a gallstone

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3
Q

def of choledocolithiasis

A

presence of gallstones in the CBD

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4
Q

aetiology of gallstones

A

Any condition associated with haemolysis eg sickle cell disease can cause pigment stone formation

mixed stones

  • contain cholesterol, calcium bilirubinate, phosphate and protein (80%)
  • due to imbalance between bile salts, phospholipids and cholesterol (supersaturation), nucleation factors and gall bladder motility

pure cholesterol stones 10%

pigment stones

  • 10%
  • black stones made of calcium bilirubinate - raised bilirubin secondary to haemolytic disorders, cirrhosis
  • brown stones due to bile duct infestation by liver fluke Clonorchis sinensis.
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5
Q

RF for mixed and cholesterol stones

A

increased age

female

obestity

DM

parenteral nutrition

drugs - oral contraceptive pill (OCP), octreotide

FH

ethnicity - pima indians

interruption of enterohepatic recirculation of bile salts eg Crohn’s

terminal ileal resection

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6
Q

RF for pigment stones

A

haemolytic disorders eg sickle cell, thalassaemia, hereditary spherocytosis

residence in far east where liver flukes are common

saint’s triad - association of gallstones, hiatus hernia and diverticulitis

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7
Q

RF for stones becoming symptomatic

A

smoking and parity

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8
Q

biliary colic

A

impaction of a gallstone in the neck of the gallbladder

Often triggered after a (fatty) meal

typically lasts < 6 hours with spontaneous resolution.

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9
Q

pathology of biliary colic

A

colic is formed by impaction of gallstone in the cystic duct

resolves when stone falls back into the gallbladder or stone remains impacted = inflammation and mucosal oedema of 3 histological grades

  • acute cholecystitis
  • acute suppurative cholecystitis
  • acute gangrenous cholecystitis

In chronic cholecystitis the pathological changes vary from microscopic evidence of chronic inflammation with the mucosa penetrating the muscle layer as Rokitansky-Aschoff sinuses to a shrunken fibrosed gallbladder with transmural fibrosis.

Rarely, dystrophic calcification occurs resulting in a ‘porcelain gall-bladder’, with increased risk of malignant transformation.

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10
Q

epi of gallstones

A

v common - 10%

3x more females in younger population, equal sex ratio after 65yrs

about 50000 cholecystectomies are performed every yr

90% are asymptomatic

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11
Q

sx of gallstones

A

90% asymptomatic - so found incidentally

biliary colic

acute cholecystitis

chronic cholecystitis

ascending cholangitis

obstructive jaundice

acute pancreatitis

cholangitis

gallstone ileus

mucocoele/empyema - obstructed bile duct fills with mucus secreted by gall bladder wall/pus

silent stones

mirizzi’s syndrome - stone in GB presses on BD = jaundice

gallbladder necrosis

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12
Q

sx of biliary colic

A

sudden onset RUQ or epigastric pain - constant - as gallbladder contracts against obstruction

may radiate to R scapula

precipitated by fatty meal pr alcohol

lasts several hours

maybe nausea and vomiting

+- jaundice

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13
Q

sx of choledocholiuthiasis

A

RUQ pain >6hr

possible jaundice

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14
Q

signs of bilairy colic

A

RUQ/epigastric tenderness

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15
Q

ix for gallstones

A

bloods

  1. FBC
  2. blood cultures
  3. amylase - at risk of pancreatitis

USS

  • demonstrates gallstones - acoustic shadow within the gallbladder
  • increased thickness of GB wall
  • dilatation of the biliary tree indicative of obstruction

AXR

  • gallstones infrequently radio-opaque (10%)
  • look for other causes of acute abdo

erect CXR - exclude perforation

ERCP

MRCP

PTC (percutaneous transhepatic cholangiography)

helical CT

urinalysis

ECG

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16
Q

ix fr choledocolithiasis

A

raised BR, GGT, ALP, AST, ALT

US - dilated bile duct, intrahepatic biliary dilatation

MRCP/ERCP = filling defect in contrast induced duct

17
Q

mx for biliary colic

A

increased complications associated with late rather than early cholecystectomy so laparoscopic cholecystectomy at the initial presentation is the optimal approach. – if not possible they should be added to waiting list for surgery within 6 weeks

conservative

  • for mild symptoms of biliary colic
  • low fat diet

medical

  • oral dissolution therapy is poorly effective - slow, and high recurrence rate
  • severe biliary colic:
  • admission
  • NBM
  • IV fluids
  • analgesic
  • anti-emetics
  • if infection - AB
  • if symptoms worsen or fail to get better: localised abscess or empyema should be suspected - drained percutaneously by cholecystostomy nad pigtail catheter
  • if obstruction - urgent biliary drainage by ERCP or PTC

surgical - laproscopic cholecystectomy

18
Q

mx for choledocholithiasis

A

supportive care, analgesics

endoscopic stone retrieval

elective cholecystectomy to prevent recurrence

19
Q

complications of biliary colic

A

stones in CBD - can cause ascending cholangitis

stones at ampulla can cause ac pancreatitis

Porcelain gallbladder is a very rare complication, secondary to chronic inflammation and is a risk factor for malignant change – look for gallbladder mural calcification on radiograph

o Stones can migrate via a fistula into the bowel with impaction and obstruction (gallstone ileus).

Mucocele of the gallbladder is caused by a stone impacting in Hartmann’s pouch obstructing the cystic duct orifice. Mucous produced by the gallbladder produces gallbladder distension, discomfort and may become infected leading to empyema of the gallbladder.

20
Q

comploications of stones in gallbladder

A

`

biliary colic

cholecystitis

mucocoele or gallbladder empyema

porcalain gallbladder

predisposition to gallbladder cancer (rare)

21
Q

complications of stones outside gallbladder

A
  • obstructive jaundice
  • pancreatitis
  • ascending cholangitis
  • perforation and pericholecystic abscess or bile peritonitis
  • cholecystenteric fistula
  • gallstone ileus - eg bouveret’s syndrome - gallstones cause gastric outlet obstruction
  • cholecystocholedochal fistula - mirrizi syndrome
22
Q

complications of cholecystectomy

A

bleeding

infection

bile leak

bile duct damage (0.3% laproscopic, 0.2% open)

postcholecystectomy syndrome - persistent dyspeptic symptoms

post-site hernias

23
Q

Px of gallstones

A

most cases benign and dont cause sig problems

surgery offers good chance of cure

yr 3 GI (52 decks)

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