Case 9: Right Upper Quadrant Pain Flashcards
the biliary system
right and left hepatic duct join to form the common hepatic duct
common hepatic duct joins the cystic duct to form the common bile duct
process of haem to bilirubin
happens inside marcrophage
haem converted to biliverdin via haem oxygenase
biliverdin converted to bilirubin via biliverdin reductase
what converts bilirubin to urobilinogen (stercobilinogen)
happens in intestine
glucuronic acid is removed via bacteria
urobilinogen can then be converted to stercobilin too
common risk factors for gall stones
common risk factors for gall stones
diet high in triglycerides, refined carbohydrates and low fibre diets
diabetes
prolonged fasting or rapid weight loss
obesity
hormone replacement therapy
female
increasing age
what are the most common type of gall stones in the UK
cholesterol stones
cholesterol stones
what are the borders of calots triangle
inferior border of liver
common hepatic duct
cystic duct
what is the importance of calots triangle
contains cystic artery (blood supply to gall bladder)
this must be identified during cholecystectomy
typical presentation of biliary colic
RUQ pain
cramping pain (comes in waves)
comes on suddenly and comes and goes over a period of weeks
can radiate to back and right shoulder blade
pain comes on shortly after eating
can get nausea during pain
pain for few hours then goes
can come on after fried foods
10/10 pain
what is biliary colic
obstruction usually by stones in the cystic duct of the biliary tree
therefore when one eats fatty foods and the gallbladder contracts to release bile, this is when the pain comes on
if your top differential was gallstones which diagnostic test would you do
trans abdominal ultrasound
triad for acute cholangitis
pyrexia
jaundice
RUQ pain
other name for gallstones
cholelithiasis
the formation of gallstones is precipitated via what
imbalance of bile salts and cholesterol
what stimulates the gall bladder to release bile
cholecystiokinin (CCK) (released via I cells inn duodenum) stimulates the gall bladder
is there an infection in biliary colic
no therefore WCC and CRP are normal
treatment of biliary colic
conservative management- fat-free diet and simple analgesia (paracetamol)
surgical management- laparoscopic cholecystectomy
what can gallstones lead to
acute cholecystitis- 1-3% of patients with symptomatic gallstones will develop acute infection of the gallbladder
acute cholangitis- about 50% of patients with acute cholangitis have gallstone aetiology
acute pancreatitis- up to 70% of acute pancreatitis cases are due to gallstone disease
when to advise someone with gall stones to attend A&E
uncontrolled pain
fever
persistent vomiting
example presentation for acute cholecystitis
RUQ pain
constant pain which started after eating
can radiate to back and right shoulder
may feel nauseous
paracetamol not making it better
9/10 pain
what is acute cholecystitis
inflammation of the gallbladder usually when gallstones block the cystic duct (gallstones remain in the gallbladder and do not obstruct the common bile duct)
examination findings for cholecystitis
abdominal pain
guarding
rebound tenderness
what can be seen in bloods with acute cholecystitis
raised WCC
raised CRP
as the gall stones do not obstruct the common bile duct there is not obstructive derangement of the LFTs
example of how to refer someone to a ward (general surgery team in case of acute cholecystitis)
SBAR
introduce yourself and say you want to refer someone, check they are in a place where they can discuss confidentially
situation- their name and presenting complaint
background- history of presenting complaint and examination and investigation findings
assessment- diagnosis and why you want to refer them (which surgery/procedure)
recommendation- would you be able to come and see this patient please with a view for hospital admission?
what does the inflammatory response in acute cholecystitis cause
wall ischaemia and infection to ensue to cause localised peritonitis (this causes the shift from the colicky pain of biliary colic to a more constant pain from peritonitis)
what would be seen on ultrasound with acute cholecystitis
thick-walled gall bladder with pericholecystic oedema
non-obstructing / no-dilated common bile duct
where are the gallstones in acute cholangitis
the common bile duct
what may happen if a gallstone gets stuck in the common bile duct
acute cholangitis
fever and jaundice
pale stools- bilirubin/bile can no longer enter duodenum
dark urine- excess conjugated bilirubin excreted via renal filtration
what is seen on ultrasound with acute cholangitis
dilated common bile duct and may see the stone itself in the common bile duct
what is first line for common bile duct imaging
USS
what other investigations can be done to image the common bile duct
MRCP (magnetic resonance cholangio-pancreatography)- this is MRI which visualises biliary tree and pancreatic ducts, non-invasive and high sensitivity for common bile duct stones
endoscopic ultrasound (EUS)- gold standard for visualising stones and other lesions in common bile duct (invasive so not done first line)
common bile duct stones causes obstructive jaundice must be what
removed prior to laparoscopic cholecystectomy
what can be seen on ultrasound with acute cholecystitis
thick walled gall bladder (indicates acute/chronic inflammation of gall bladder)
pericholecystic fluid (fluid around the oedematous gall bladder) is an acute finding
management and treatment of acute cholecystitis
analgesia
antibiotics
antiemetics
fluid blance (intravenous)
venous thromboembolism prophylaxis
NBM in anticipation for surgery- laparoscopic cholecystectomy
possible complications of laparoscopic cholecystectomy
general= bleeding, infection, pain, chest and urinary infections, DVT/PE (associated with general anaesthetic)
specific=
damage to common bile duct
bile leak
damage to surround structures (duodenum/stomach)
conversion from laparoscopic procedure to open procedure
Reynolds pentad for cholangitis
mental status alterations
sepsis
what can be seen on bloods with acute cholangitis
raised inflammatory markers
obstructive pattern of jaundice to the LFTs suggesting CBD obstruction
what is acute cholangitis
infection of the biliary tree caused by downstream obstruction of the common bile duct
how can acute cholangitis lead to sepsis
there is translocation of bacteria from biliary system as biliary pressure increases due to obstruction- cholangitis with sepsis
causes of acute cholangitis
cholelithiasis
benign biliary structure
sclerosing cholangitis
malignant strictures
risk factors for acute cholangitis
increasing age
history of gallstones, biliary strictures or sclerosing cholangitis
previous biliary surgery that may lead to narrowing of the bile duct
what investigation helps investigate the cause of biliary obstruction (cholangitis)
ultrasound
treating common bile duct obstruction (cholangitis)
either remove cause (stone) or relieve obstruction using stent (in the case of stricture)
can do this via ERCP
how does ERCP work
side viewing endoscope identifies and cannulates the ampulla of Vater which opens into second part of the duodenum
radio-opaque dye is injected and passes up into CBD, common hepatic duct and pancreatic duct
x-rays visualise the dye to detect any filling defects that could indicate a stone or stricture
advantage of ERCP
can be used to perform therapeutic procedures in the same procedure
can extract stones using wire basket
can do sphincterotomy of sphincter of Oddi (to allow better passage of bile)
can inset stent across obstruction to relieve jaundice
when is ERCP not therapeutic
not therapeutic for stones in the gall bladder or cystic duct
risks of ERCP
not used as diagnostic procedure due to risks
risks:
acute pancreatitis (5%)
gastric/duodenal perforation
bleeding (usually from artery near sphincter of Oddi particularly if sphincterotomy is performed)
risks associated with sedation is required for procedure
management and treatment of acute cholangitis
analgesia
antibiotics
antiemetics
fluid balance (IV and urinary catheter)
venous thromboembolism prophylaxis
NBM (in preparation for ERCP)
which blood result is most useful to diagnose ERCP-induced pancreatitis
lipase
how would you treat acute pancreatitis secondary to ERCP
analgesia
antiemetics
no antibiotics (however patient will be on then if have cholangitis)
fluid balance (IV fluids and urinary catheter)
venous thromboembolism prophylaxis
biliary colic vs cholecystitis vs cholangitis
biliary colic= RUQ pain due to obstruction of a bile duct by a gallstone
cholecystitis= inflammation of the gall bladder wall (usually caused by obstruction of the bile ducts by gall stones)
cholangitis= inflammation of the bile ducts
