Biliary tract disease

Question 1

Epidemiology of gallstones

Answer 1

4Fs

1. Fat
2. Female
3. Forty
4. Fertile

Question 2

Types of gallstone

Answer 2

1. Cholesterol - excess causes crystals to form, large, solitary
2. Pigment - excess bilirubin (from chronic haemolysis)
3. Mixed

Question 3

Symptoms of biliary colic

Answer 3

1. RUQ pain, sudden, dull, radiating to back and epigastrium
2. Nausea + vomiting
3. Precipitated by fatty foods

Question 4

Diagnosis of biliary colic (gallstone obstruction)

Answer 4

1. Ultrasound
2. LFTs - ALP raised
3. Urinalysis
4. MRCP

Question 5

Pathology of biliary colic

Answer 5

Stone becomes impacted in neck of gallbladder. There is no inflammation, the pain comes from contraction of the neck.

Question 6

Differential diagnosis RUQ pain

Answer 6

1. GORD
2. Peptic ulcer
3. Pancreatitis (acute)
4. IBD

Question 7

Treatment of biliary colic

Answer 7

1. Analgesia
2. Lifestyle advice - low fat diet, weight loss, exercise
3. Elective laparoscopic cholecystectomy

Question 8

Define acute cholecystitis

Answer 8

Inflammation of the gallbladder due to stone in the neck. Obstruction to bile emptying.

Question 9

RF acute cholecystitis

Answer 9

1. Obesity

2. DM

Question 10

Symptoms of acute cholecystitis

Answer 10

1. Constant RUQ pain
2. Tenderness
3. Nausea + vomiting
4. Fever
5. Lethargy
6. Positive Murphy’s sign
7. NO JAUNDICE - difference from ascending cholangitis

Question 11

Murphy’s sign

Answer 11

Apply pressure on RUQ and ask patient to inspire. The patient will halt inspiration if there is pain - inflamed gallbladder

Question 12

Investigations for acute cholecystitis

Answer 12

1. Ultrasound
2. LFTs - ALP raised
3. CRP, ESR

Question 13

Treatment for acute cholecystitis

Answer 13

1. Analgesia + IV fluids + anti-emetics
2. Antibiotics - co-amox/metranidazole
3. Laparoscopic cholecystectomy
4. Percutaneous cholecystectomy (if not fit for surgery)

Question 14

Define ascending cholangitis

Answer 14

Inflammation of the gallbladder due to stone in neck - > infection of the biliary tree - usually flow of bile prevents intestinal bacteria moving into the gallbladder.

Question 15

Common bacteria causing ascending cholangitis

Answer 15

1. E.coli
2. Klebsiella
3. Enterococcus (group D strep)

Question 16

Signs of ascending cholangitis

Answer 16

Charcot's triad:
1. Fever (with chills)
2. RUQ pain
3. Jaundice (dark urine, pale stool, pruritis)
Reynold's pentad = Charcot's triad +:
1. Confusion
2. Hypotension

Question 17

Investigations for ascending cholangitis

Answer 17

1. Bloods: LFTS (ALP, ALT, AST raised), CRP, ESR
2. Ultrasound abdomen
3. Blood culture - if septic
4. MRCP/ERCP

Question 18

Treatment of ascending cholangitis

Answer 18

1. IV fluids + antibiotics
2. Analgesia
3. ERCP to clear
4. Stenting