Biliary Colic And Cholecystitis Flashcards
What is bile formed from?
Cholesterol
Phospholipids
Bile pigments (products of haemoglobin metabolism)
How do gallstones from and what are the three types?
Supersaturation of the bile
Cholesterol stones - excess cholesterol production - poor diet and obesity
Pigment stones - excess bile pigment, commonly in haemolytic anaemia
Mixed stones
What are the risk factors for gallstones?
5 Fs - Fat, Female, Fertile, Forty and Family history
Other includes - pregnancy, oral contraceptive, haemolytic anaemia and malabsoprtion (previous ileal resection or Crohns disease)
What are two symptomatic ways gallstones can present?
Billary colic
Acute cholecystitis
What is biliary colic?
Gallbladder neck impacted by a gallstone - no inflammatory response but contraction of the gallbladder against occluded neck results in pain.
Pain is sudden, dull and colicky - RUQ may radiate to epigastrium or back. May be precipitated by consumption of fatty foods
May have N/V. Pain relief causes symptoms to settle quickly.
What is acute cholecystitis?
Constant pain in RUQ or epigastrium assoicated with signs of inflammation such as fever or lethargy.
Tender RUQ and may demostrate positive Murphys sign. Ensure to check for guarding as sign of perforation and sepsis.
What is murphys sign?
Apply pressure in RUQ and ask pt to inspire. It is positive if pt isin pain when inspiring. This can be done more accuratly using ultrasound, namely th sonographic Murphy sign.
What are the differential diagnosis for gallstones?
GORD
PUD
Acute pancreatitis
IBD
What laboratory test should be order in supected gallstones?
FBC and CRP
LFTS - raised ALP
Amylase/lipase - rule out pancreatitis
Urinalysis including pregnancy test - rule out renal or tubo-ovarian pathology
What imaging should b requested in supected galltones?
Trans-abdominal ultrasound - frst line - look for presence of gallstones or sludge, gallbladder wall thickness, bile duct dilatation.
Gold standard if ultrasounf inconclusive - magnetic resonance cholangiopancreatography (MRCP).
What is the management for billary colic?
Analgesia and lifestyle advise - low fat diet, weight loss and increasing exercise
High chance of recurrence and development of complications of gallstones - elective laproscopic cholecystectomy - should be offered with 6 weeks of first presntation.
What is the managment of acute cholecystitis?
IV antibiotics (co-amoxicalv +/- metronidazole) Analgesics and anti-emetics
Laproscopic cholecystectomy within 1 week of presntation but ideally withi 72 hrs
If not fit for surgery and not responding to antibiotics - percutaneous cholecystostomy - drain infection
What need to be excluded if patient re-admitted with RUQ pain post-cholecystectomy?
Retained CBD stone - US and MRCP
What are the complications of gallstones?
Mirizzi syndrome
Gallbladder empyema
Chronic cholecystitis
Bouverts syndrome and gallstone ileus
What is mirizzi syndrome?
A stone located in Hartmanns pouch or in cystic duct itself causing compression on the adjancet common hepatic duct. Caused obstructive jaundice. Confrimed by MRCP and requires larproscopic cholecystectomy.
What is gallbladder empyema?
Gallbldder filled with pus. Pts will become unwell, often septic presnting with similar picture to acute Cholecystitis.
Diagnosed using US or CT scan
Requires laparoscopic cholecystectomy (may require intra-op drainage) - higher rate of conversion to open surgery. Percutaneous cholecystostomy if unsutible for surgery.
What is chronic cholecystitis?
Typically have history of reccurent or untreated cholecystitis, persitant inflammtion of gallbladder wall.
Ongoing RUQ or epigastric pain.
Diagnosed by CT imaging.
Uncomplcated cases require elective cholecystectomy.
Main complication: gallbladder carcinoma and biliary-enteric fistula
What is the pathophysiology of Bouverts syndrome and gallstone ileus?
Inflammation of gallbladder can cause fsitula to form between gallbladder wall and small bowel, called cholecystoduodenal fistula. This allows gallstones to pass directly into small bowel.
What is bouverts syndrome?
Stone impacts in proximal duodenum causes gastric oulet obstruction.
What is gallstone ileua?
A stone impacts at the termianl ileum, causing small bowel obstruction
