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Y4: Acute surgery > Biliary colic and cholecystitis > Flashcards

Biliary colic and cholecystitis Flashcards

1
Q

Bilary tree

A
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2
Q

Describe the pathophysiology of gallstone disease?

A
  • Bile is formed from choelsterol, phospholipids and bile pigments
  • Stored in gallbladder before passing into the duodenum when stimulated
  • Gallstones form as a result of supersaturation of bile
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3
Q

What are the main types of gallstones?

A
  • Cholesterol stones
    • Link between poor diet, obesity and cholesterol stones
  • Pigment stones
    • Seen in those with known haemolytic anaemia
  • Mixed stones
    • Composed of both cholesterol and bile pigments
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4
Q

What are the risk factors for gallstones?

A
  • Fat
  • Female
  • Fertile
  • Forty
  • Family history
  • Pregnancy, oral contraceptives, haemolytic anaemia, malasorption
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5
Q

What is the link between oral contraceptives and bile stones?

A

Oestrogen causes more cholesterol to be secreted into bile

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6
Q

Describe biliary colic?

A
  • Occurs when the gallbladder neck becomes impacted by a gallstone
  • No inflammatory response
  • Contraction of gallbladder against occluded neck causes the pain
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7
Q

Describe the pain of biliary colic?

A
  • Sudden, dull, colicky
  • Right upper quadrant, can radiate to epigastrium/back
  • Precipitated by the consumption of fatty foods
  • May be associated with nausea and vomiting
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8
Q

Why does the consumption of fatty foods exacerbate biliary colic?

A
  • Stimulate the duodenum endocrine cells to release cholecystokinin (CCK)
  • CCK stimulates contraction of the gallbladder
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9
Q

Describe the symptoms of acute cholecystitis?

A
  • Similar to biliary colic but the pain can be constant and continue despite pain relief
  • Associated with signs of inflammation (fever, raised WCC)
  • Derangement of LFTs
  • Tender in RUQ with a positive Murpheys sign
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10
Q

What is Murpheys sign?

A
  • Whilst applying pressure in the RUQ, ask the patient to inspire
  • Murphys sign is positive when there is a halt in inspiration due to pain
  • Indicates an inflamed gallbladder
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11
Q

Describe the investigations that should be performed with someone who has suspected gallstone disease?

A
  • Urinalysis (including pregnancy test)
  • FBC, CRP, U&Es
  • LFTs (raised ALP: ductal occlusion, other LFTs will be normal)
  • Amylase to exclude pancreatitis
  • Imaging:
    • 1st line: Transabdominal US
    • 2nd line: MRCP
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12
Q

What can be visualised on transabdominal US to help in the diagnosis of gallstone disease?

A
  • Presence of gallstones or sludge
  • Gallbladder wall thickness
  • Bile duct dilatation
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13
Q

Describe the use of MRCP in diagnosing gallstone disease?

A
  • Can show defects in the biliary tree
  • Near 100% sensitivity
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14
Q

Describe the initial management of biliary colic?

A
  • Analgesia
    • NSAIDs + PRN opioids
  • Anti-emetic
  • Advised about lifestyle factors:
    • Low fat diet, weight loss, increased exercise
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15
Q

Describe the definitive management of biliary colic?

A

Elective cholecystectomy

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16
Q

Describe the initial management of Acute cholecystitis?

A
  • IV antibiotics (co-amoxiclav +/- metronidazole)
  • Fluid resuscitation
  • NG tube if patient is vomiting
  • Analgesia
  • Antiemetics
17
Q

Describe the definitive management of Acute cholecystitis?

A
  • Laparoscopic cholecystectomy within 1 week
    • Ideally within 72 hours of presentation
  • If not fit for surgery/antibiotics not working
    • Percutaneous cholecystectomy
18
Q

Name some complications of gallstones disease?

A
  • Gallbladder empyema
  • Chronic cholecystitis
  • Bouveret’s syndrome
  • Gallstone ileus
  • Mucocoele
19
Q

Describe gallbladder empyema as a complication of gallstone disease?

A
  • Gallbladder is infected and an abscess forms
  • Patients are typically septic
  • Diagnosed by US or CT
  • Laproscopic cholecystectomy is the treatment
    • May require conversion to open surgery
20
Q

Describe chronic cholecystitis as a complication of gallstone disease?

A
  • Recurrent/untreated cholecystitis => chronic inflammation of GB wall
  • Asymptomatic or ongoing RUQ/epigastric pain
    • With N/V
  • Diagnosed by CT scan
  • Elective cholecystectomy to treat
    • Increased risk of gallbladder carcinoma and biliary-enteric fistula
21
Q

Describe Bouveret’s syndrome as a complication of gallstone disease?

A
  • Inflammation of gallbldder => fistula forms to duodenum
    • Gallstones pass into the small bowel
  • Stone impacts to cause duodenal obstruction
22
Q

Describe Gallstone ileus as a complication of gallstone disease?

A
  • Inflammation of gallbldder => fistula forms to duodenum
    • Gallstones pass into the small bowel
  • Stone impacts to cause an obstruction at the terminal ileum
23
Q

Describe a mucocoele?

A
  • Develops when the outlet of the gall bladder becomes obstructed in the absence of infection
  • The imprisoned bile is absorbed but clear muus continues to be secreted into the distended gall bladder
24
Q

What bacteria can commonly cause Acute cholecystitis?

A
  • E. coli
  • Klebsiella aerogenes
  • Strep. faecalis
25
Q

How can E coli cause brown pigment stones?

A
  • Increased amounts of unconjugated bilirubin in the bile
  • Due to the action β-glucoridase
26
Q

What are the different types of pigment gall stones?

A
  • Black
    • In Western countries
    • Calcium salts of bilirubin, phosphate, bicarbonate
  • Brown
    • In Far East countries
    • Calcium salts of bilirubin, stearates, palmitrates, cholesterol
27
Q

What is the most common cause of prolonged jaundice in infancy?

A

Biliary atresia

28
Q

Describe the appearance of pure cholesterol stones?

A

Yellowish green with a regular surface

29
Q

Describe the appearance of pigment gallstones?

A
  • Multiple, small stones
  • Calcium . bilirubinate
30
Q

What is Mirizzi’s syndrome?

A

When gallstones erode through the gallbladder into the hepatic or bile duct

31
Q

Describe the jaundice which gallstones can cause when they obstruct bile flow through the sphincter of Oddi?

A
  • Jaundice
  • Palce stools
  • Dark urine
32
Q

What is the triad of cholangitis?

A
  • Obstructed biliary tract causing Charcot’s triad:
    • Pain
    • Pyrexia
    • Jaundice
  • Can also be associated with rigors

Y4: Acute surgery (9 decks)

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