Biliary colic and cholecystitis Flashcards
what forms bile?
cholesterol
phospholipids
bile pigments
why do gallstones form?
as a result of supersaturation of bile
what are the 3 main types of gallstones?
1) cholesterol stones, from excess cholesterol production (common in those with a poor diet)
2) pigment stones, made of bile pigments from excess bile production (common in those with haemolytic anaemia)
3) mixed stones - cholesterol and bile pigments
what are the risk factors for gallstone disease?
5 F’s
- fat
- female
- fertility
- forty
- family history
others
- pregnancy
- oral contraceptives (oestrogen causes more cholesterol to be secreted into bile)
- haemolytic anaemia (for pigment stones)
- malabsorption e.g previous ileal resection or crohns
when does biliary colic occur?
when the gallbladder neck becomes impacted by a gallstones
no inflammatory response, , but the contraction of the gallbladder against the occluded neck will cause pain
what are the clinical features of biliary colic?
Pain is
- sudden
- dull
- colicky in nature
- focused in RUQ but may radiate to epigastrium and/or back
- precipitated by consumption of fatty food
patient also complains of nausea and vomitting
what stimulates contraction of the gallbladder?
Cholecystokinin (CCK)
fatty acids stimulate the duodenum endocrine cells to release CCK which stimulates gallbladder contraction
what are the clinical features of acute cholecystitis?
- constant pain in RUQ or epigastrium
- signs of inflammation e.g fever or lethargy
- tender RUQ
- positive Murphy’s sign
- check for guarding (suggests gallbladder perforation)
- check for features of sepsis
what is Murphy’s sign?
Apply pressure to RUQ
ask patient to inspire
positive sign if there is a halt in inspiration due to pain, indicating an inflamed gallbladder e.g in cholecystitis
can be achieved more acutely with USS
what are your differentials in RUQ pain?
mainly different pathologies
important to consider
- GORD
- peptic ulcer disease
- acute pancreatitis
- IBD
as well as biliary disease
what laboratory investigations can be done into RUQ pain?
bloods
- FBC and CRP to asses for inflammatory response e.g in cholecystitis
- LFTs. Biliary colic and acute cholecystitis will show raised ALP (indicate ductal occlusion) but ALT and bilirubin will stay normal.
- Amylase or lipase to check for pancreatitis
- urinalysis and pregnancy test if needed.
what imaging can be done into RUQ pain?
trans abdominal USS is first line to check for gallstone pathology
- gallstones or sludge (start of gallstone formation)
- gallbladder wall thickness (thick = indicates inflammation)
- bile duct dilation (indicates stone in distal bile ducts)
if inconclusive further imaging is available
what is the gold standard investigation for gallstones?
MRCP (magnetic resonance cholangiopancreatography), replacing ERCP for diagnostic purposes
can show defects in biliary tree caused by gallstone disease
what is the management for biliary colic?
- analgesia (paracetamol/NSAIDS/ opiates)
- advise about lifestyle factors to help symptoms e.g low fat diet, weight loss and exercise
- high chance of symptom recurrence and complication development, so elective laparoscopic cholecystectomy is offered within 6 weeks of presentation
what is the management for acute cholecystitis?
- IV antibiotics e.g co amoxiclav (+/- metronidazole)
- analgesia
- anti emetics
- laparoscopic cholecystectomy within 1 week of presentation, but aim for within 72hrs for a simpler procedure
- not fit for surgery/not responding to antibiotics, a percutaneous cholecystostomy can be performed to drain the infection (although gallstones remain in situ so risk of recurring disease remains)
a patient is readmitted with RUQ pain following a cholecystectomy for acute cholecystitis. what do you need to exclude?
if readmitted with RUQ pain post cholecystectomy, need to exclude retained CBD stone.
US abdominal may be useful, but if unremarkable, MRCP.
what is mirizzi syndrome?
a stone located in Hartmanns pouch (pouch of gallbladder at junction with cystic duct) or the cystic duct itself can cause compression of the common hepatic duct
the result is obstructive jaundice
confirm diagnosis with MRCP and treat with laparoscopic cholecystectomy
what is the usually history for chronic cholecystitis?
history of recurrent or untreated cholecystitis = persistent inflammation of the gallbladder wall
what do patients with chronic cholecystitis present with and how is it diagnosed and managed?
present with ongoing RUQ or epigastric pain with nausea and vomiting
diagnosed typically by CT imaging
manage with elective cholecystectomy
what are the complications of chronic cholecystitis?
- gallbladder carcinoma
- biliary enteric fistula
what is a cholecystoduodenal fistula?
inflammation of the gallbladder (typically if recurrent) can cause a fistula to form between the gallbladder wall and the small bowel
what are the consequences of a cholecystoduodenal fistula?
bowel obstruction
- Bouverets syndrome = a stone impacts proximal duodenum causing gastric outlet obstruction
- gallstone ileus = stone impacts terminal ileum (narrowest part of small bowel) causing small bowel obstruction
true of false: most people with gallstones are asymptomatic
true
1-4% will develop symptoms secondary to gallstones
