Biliary colic and cholecystitis Flashcards
Bilary tree
Describe the pathophysiology of gallstone disease?
- 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
What are the main types of gallstones?
- 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
What are the risk factors for gallstones?
- Fat
- Female
- Fertile
- Forty
- Family history
- Pregnancy, oral contraceptives, haemolytic anaemia, malasorption
What is the link between oral contraceptives and bile stones?
Oestrogen causes more cholesterol to be secreted into bile
Describe biliary colic?
- Occurs when the gallbladder neck becomes impacted by a gallstone
- No inflammatory response
- Contraction of gallbladder against occluded neck causes the pain
Describe the pain of biliary colic?
- 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
Why does the consumption of fatty foods exacerbate biliary colic?
- Stimulate the duodenum endocrine cells to release cholecystokinin (CCK)
- CCK stimulates contraction of the gallbladder
Describe the symptoms of acute cholecystitis?
- 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
What is Murpheys sign?
- 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
Describe the investigations that should be performed with someone who has suspected gallstone disease?
- 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
What can be visualised on transabdominal US to help in the diagnosis of gallstone disease?
- Presence of gallstones or sludge
- Gallbladder wall thickness
- Bile duct dilatation
Describe the use of MRCP in diagnosing gallstone disease?
- Can show defects in the biliary tree
- Near 100% sensitivity
Describe the initial management of biliary colic?
- Analgesia
- NSAIDs + PRN opioids
- Anti-emetic
- Advised about lifestyle factors:
- Low fat diet, weight loss, increased exercise
Describe the definitive management of biliary colic?
Elective cholecystectomy
Describe the initial management of Acute cholecystitis?
- IV antibiotics (co-amoxiclav +/- metronidazole)
- Fluid resuscitation
- NG tube if patient is vomiting
- Analgesia
- Antiemetics
Describe the definitive management of Acute cholecystitis?
- Laparoscopic cholecystectomy within 1 week
- Ideally within 72 hours of presentation
- If not fit for surgery/antibiotics not working
- Percutaneous cholecystectomy
Name some complications of gallstones disease?
- Gallbladder empyema
- Chronic cholecystitis
- Bouveret’s syndrome
- Gallstone ileus
- Mucocoele
Describe gallbladder empyema as a complication of gallstone disease?
- 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
Describe chronic cholecystitis as a complication of gallstone disease?
- 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
Describe Bouveret’s syndrome as a complication of gallstone disease?
- Inflammation of gallbldder => fistula forms to duodenum
- Gallstones pass into the small bowel
- Stone impacts to cause duodenal obstruction
Describe Gallstone ileus as a complication of gallstone disease?
- Inflammation of gallbldder => fistula forms to duodenum
- Gallstones pass into the small bowel
- Stone impacts to cause an obstruction at the terminal ileum
Describe a mucocoele?
- 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
What bacteria can commonly cause Acute cholecystitis?
- E. coli
- Klebsiella aerogenes
- Strep. faecalis
How can E coli cause brown pigment stones?
- Increased amounts of unconjugated bilirubin in the bile
- Due to the action β-glucoridase
What are the different types of pigment gall stones?
- Black
- In Western countries
- Calcium salts of bilirubin, phosphate, bicarbonate
- Brown
- In Far East countries
- Calcium salts of bilirubin, stearates, palmitrates, cholesterol
What is the most common cause of prolonged jaundice in infancy?
Biliary atresia
Describe the appearance of pure cholesterol stones?
Yellowish green with a regular surface
Describe the appearance of pigment gallstones?
- Multiple, small stones
- Calcium . bilirubinate
What is Mirizzi’s syndrome?
When gallstones erode through the gallbladder into the hepatic or bile duct
Describe the jaundice which gallstones can cause when they obstruct bile flow through the sphincter of Oddi?
- Jaundice
- Palce stools
- Dark urine
What is the triad of cholangitis?
- Obstructed biliary tract causing Charcot’s triad:
- Pain
- Pyrexia
- Jaundice
- Can also be associated with rigors
