Case 12 Abdominal pain

Question 1

• What should Immediate assessment of the acute abdomen focus on?

Answer 1

Distinguishing patients with true acute abdomen that requires urgent surgical intervention from patients who can initially be managed conservatively

Question 2

Which individuals can have acute abdomen without pain

Answer 2

older people, children, and the immunocompromised, and in the last trimester of pregnancy.

Question 3

• What is the issue likely to be if there is severe epigastric pain?
• What are some of the systemic causes of upper abdominal pain?

Answer 3

Myocardial infarction

Addisonian crisis
Diabetic ketoacidosis
Electrolyte insufficiencies

Question 4

• What is the pathophysiology behind biliary colic?

Answer 4

Gallstones stuck in the cystic duct temporarily so when CCK stimulates contraction of the gallbladder (post-prandial), after a fatty meal, this causes pain, No inflammation.

Question 5

• What is the pathophysiology behind cholecystitis?

Answer 5

Gallstones stuck in the cystic duct causes inflammation of the cystic duct and gallbladder and bile gets trapped in the gallbladder

Question 6

• What is the general pathophysiology behind cholangitis?

Answer 6

Inflammation and infection of the biliary tree due to obstruction of bile flow

Question 7

• Does biliary colic, cholecystitis and cholangitis have RUQ pain, fever, and jaundice?

Answer 7

BC- just pain
cholecystitis - pain and fever
cholangitis- all three (charcots triad). Jaundice as bilirubin not secreted from liver.

nausea and vomiting are present in BC and cholecystitis

Question 8

• What is Murphy’s sign?

Answer 8

When palpating the RUQ upon inhalation, the gallbladder is felt due to inflammation. inhalation diaphragm pushes it down. in acute cholecystitis

Question 9

• What are the Two types of gallstones?

Answer 9

pigment (bilirubin) gallstones
cholesterol gallstones (80%)

Question 10

• What are the 3 factors that encourage gallstone formation?

Answer 10

Cholesterol supersaturation

Gallbladder hypomotility possibly due to low or inactive CCK

Kinetic factors (nucleation) - promoting crystallisation of cholesterol

Question 11

• What are the risk factors for cholesterol stones?

Answer 11

Obesity - increased cholesterol in bile

Hyperlipidaemia - increased hepatic cholesterol secretion

Female gender - oestrogen is associated with the cholesterol metabolism

Female, fat , fertile, forty

Question 12

• What is a risk factor for bilirubin stones?

Answer 12

Haemolytic anaemia - increased bilirubin supersaturation

Question 13

• How does gallstone ileus occur?

Answer 13

Gallstone grows in size in the gallbladder

This then rubs against the wall of the gallbladder until it perforates through it mechanically into the small intestine

This forms a fistula between the small intestine and the fundus of the gallbladder

The gallstone then travels into the small intestine until it gets lodged in the ileocaecal valve

Question 14

• Complications of gallstones

Answer 14

galllstone pancreatitis
acute cholecystitis
causing billiary obstruction
gallstone illeus
billiary fistula
Mirizzis Syndrome
Bouveret syndrome

Question 15

• What are the general complications of a Laproscopic Cholecystectomy

Answer 15

Infection, bleeding, injury to other parts of abdomen, deep vein thrombosis

Question 16

What are some of the specific complications of a laparoscopic cholecystectomy?

Answer 16

Diarrhoea, injury to bile duct

Question 17

• What are brown pigment stones associated with?

Answer 17

Infections of the biliary tract

Question 18

• What do black pigment stones consist of?

Answer 18

Calcium bilirubinate, often found in patients with haemolytic anaemia.

Question 19

What is bile composed of

Answer 19

• Bile is composed of
  cholesterol, bilirubin, water, bile salts, phospholipids, and ions.

Question 20

What is the initial test of choice to diagnose most disorders of the gallbladder?

Answer 20

an abdominal ultrasound.

X-ray is less sensitive, as calcified gallstones are only seen on plain abdominal x-rays in about 10% of patients with cholelithiasis.

Question 21

• What scan is done during an emergency department visit to evaluate abdominal pain.

Answer 21

CT scan

Question 22

• What is choledocholithiasis?

Answer 22

Gallstone lodged in the common bile duct

Question 23

• What do you need to do to gain consent for a procedure?

Answer 23

knowledge of procedure

explain diagnosis

treatment options

purpose of procedure

risks

Question 24

• What happens in Mirizzi’s syndrome?
• What happens in Bouveret syndrome?

Answer 24

Common hepatic duct obstruction caused by extrinsic compression from an enlarged impacted stone in the cystic duct

When the stone lodges in the upper part of the duodenum causing gastric outlet obstruction

Question 25

how is cholesterol made soluble

Answer 25

Cholesterol is made soluble in bile through mixed micelles with bile salts and phospholipids, mainly phosphatidylcholine (lecithin).

Question 26

how does supersaturation of cholesterol cause gallstones

Answer 26

Supersaturation of cholesterol occurs when the cholesterol concentration exceeds the concentration at which it remains soluble. This can result in the formation of vesicles that may aggregate as solid cholesterol crystals to form stones.

Question 27

how does immobility of bile cause gallstone formation?

Answer 27

As supersaturated bile is found in healthy individuals, the microcrystals formed are effectively flushed from the gallbladder during postprandial contractions. so impaired bile mobility would cause the crystals to be stuck and not flushed away

Question 28

how do Kinetic factors affect gallstone formation.

Answer 28

The formation of microcrystals in supersaturated bile is modulated by kinetic protein factors such as nucleation-promoting proteins. Mucin is an example of a pro nucleating factor that promotes the crystallisation of bile.

Question 29

How is CCK released

Answer 29

Specialized enteroendocrine cells called I-cells are located in the duodenum and jejunum. When these cells are stimulated by fatty acids and amino acids released from the stomach, a peptide hormone called cholecystokinin (CCK) is released

Question 30

- what are the two main functions of CCK pertaining to the gallbladder?

Answer 30

Its first function is to stimulate the smooth muscle of the gallbladder to contract and release bile into the biliary tree. The second function of CCK is to simultaneously signal the muscular sphincter of Oddi to relax.

Question 31

- what is an example of teatment of gallbladder pathology apart from surgery

Answer 31

An example is bile acid sequestrants that prevent reabsorption of bile acids in the ileum and lead to lower cholesterol levels as the body is forced to use it as a substrate to produce new bile acids

Question 32

what are drugs that may increase the risk of gallstone formation ?

Answer 32

hormone replacement therapy containing estrogen causes increased levels of cholesterol. Somatostatin analogs such as octreotide block the release of CCK and lead to the formation of biliary sludge. Fibrates block the rate-limiting enzyme 7-alpha-hydroxylase causing increased cholesterol and decreased bile acid production.

Question 33

- Upon auscultation, if you hear a tinkling sound, what is this a sign of? - Upon auscultation, if you hear no bowel sounds, what is this a sign of?

Answer 33

Early bowel obstruction Later sign of obstruction or peritonitis

Question 34

- Is it visceral or parietal pain that is well localised? - Is it visceral or parietal pain that is dull and achey?

Answer 34

Parietal Visceral

Question 35

- When bile cannot enter the duodenum, what happens?

Answer 35

Jaundice as there is a buildup of bilirubin which causes yellowing of skin, eyes and mucous membranes as well as alcoholic stools

Question 36

- What is the most sensitive and specific diagnostic test to confirm cholecystitis?

Answer 36

Hepatobiliary iminodiacetic acid (HIDA) scan AKA cholescintigraphy

Question 37

- What are the treatment options for acute cholecystitis?

Answer 37

Analgesia and fluids Consider Abx Early delayed cholecystectomy (laproscopic)