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Semester 1 ( 3rd Year) > Case 9: Right Upper Quadrant Pain > Flashcards

Case 9: Right Upper Quadrant Pain Flashcards

1
Q

the biliary system

A

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

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2
Q

process of haem to bilirubin

A

happens inside marcrophage

haem converted to biliverdin via haem oxygenase

biliverdin converted to bilirubin via biliverdin reductase

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3
Q

what converts bilirubin to urobilinogen (stercobilinogen)

A

happens in intestine

glucuronic acid is removed via bacteria

urobilinogen can then be converted to stercobilin too

common risk factors for gall stones

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4
Q

common risk factors for gall stones

A

diet high in triglycerides, refined carbohydrates and low fibre diets

diabetes

prolonged fasting or rapid weight loss

obesity

hormone replacement therapy

female

increasing age

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5
Q

what are the most common type of gall stones in the UK
cholesterol stones

A

cholesterol stones

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6
Q

what are the borders of calots triangle

A

inferior border of liver
common hepatic duct
cystic duct

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7
Q

what is the importance of calots triangle

A

contains cystic artery (blood supply to gall bladder)
this must be identified during cholecystectomy

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8
Q

typical presentation of biliary colic

A

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

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9
Q

what is biliary colic

A

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

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10
Q

if your top differential was gallstones which diagnostic test would you do

A

trans abdominal ultrasound

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11
Q

triad for acute cholangitis

A

pyrexia
jaundice
RUQ pain

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12
Q

other name for gallstones

A

cholelithiasis

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13
Q

the formation of gallstones is precipitated via what

A

imbalance of bile salts and cholesterol

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14
Q

what stimulates the gall bladder to release bile

A

cholecystiokinin (CCK) (released via I cells inn duodenum) stimulates the gall bladder

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15
Q

is there an infection in biliary colic

A

no therefore WCC and CRP are normal

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16
Q

treatment of biliary colic

A

conservative management- fat-free diet and simple analgesia (paracetamol)

surgical management- laparoscopic cholecystectomy

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17
Q

what can gallstones lead to

A

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

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18
Q

when to advise someone with gall stones to attend A&E

A

uncontrolled pain
fever
persistent vomiting

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19
Q

example presentation for acute cholecystitis

A

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

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20
Q

what is acute cholecystitis

A

inflammation of the gallbladder usually when gallstones block the cystic duct (gallstones remain in the gallbladder and do not obstruct the common bile duct)

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21
Q

examination findings for cholecystitis

A

abdominal pain
guarding
rebound tenderness

22
Q

what can be seen in bloods with acute cholecystitis

A

raised WCC
raised CRP
as the gall stones do not obstruct the common bile duct there is not obstructive derangement of the LFTs

23
Q

example of how to refer someone to a ward (general surgery team in case of acute cholecystitis)

A

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?

24
Q

what does the inflammatory response in acute cholecystitis cause

A

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)

25
Q

what would be seen on ultrasound with acute cholecystitis

A

thick-walled gall bladder with pericholecystic oedema
non-obstructing / no-dilated common bile duct

26
Q

where are the gallstones in acute cholangitis

A

the common bile duct

27
Q

what may happen if a gallstone gets stuck in the common bile duct

A

acute cholangitis

fever and jaundice

pale stools- bilirubin/bile can no longer enter duodenum

dark urine- excess conjugated bilirubin excreted via renal filtration

28
Q

what is seen on ultrasound with acute cholangitis

A

dilated common bile duct and may see the stone itself in the common bile duct

29
Q

what is first line for common bile duct imaging

A

USS

30
Q

what other investigations can be done to image the common bile duct

A

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)

31
Q

common bile duct stones causes obstructive jaundice must be what

A

removed prior to laparoscopic cholecystectomy

32
Q

what can be seen on ultrasound with acute cholecystitis

A

thick walled gall bladder (indicates acute/chronic inflammation of gall bladder)

pericholecystic fluid (fluid around the oedematous gall bladder) is an acute finding

33
Q

management and treatment of acute cholecystitis

A

analgesia
antibiotics
antiemetics
fluid blance (intravenous)
venous thromboembolism prophylaxis
NBM in anticipation for surgery- laparoscopic cholecystectomy

34
Q

possible complications of laparoscopic cholecystectomy

A

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

35
Q

Reynolds pentad for cholangitis

A

mental status alterations
sepsis

36
Q

what can be seen on bloods with acute cholangitis

A

raised inflammatory markers
obstructive pattern of jaundice to the LFTs suggesting CBD obstruction

37
Q

what is acute cholangitis

A

infection of the biliary tree caused by downstream obstruction of the common bile duct

38
Q

how can acute cholangitis lead to sepsis

A

there is translocation of bacteria from biliary system as biliary pressure increases due to obstruction- cholangitis with sepsis

39
Q

causes of acute cholangitis

A

cholelithiasis
benign biliary structure
sclerosing cholangitis
malignant strictures

40
Q

risk factors for acute cholangitis

A

increasing age
history of gallstones, biliary strictures or sclerosing cholangitis
previous biliary surgery that may lead to narrowing of the bile duct

41
Q

what investigation helps investigate the cause of biliary obstruction (cholangitis)

A

ultrasound

42
Q

treating common bile duct obstruction (cholangitis)

A

either remove cause (stone) or relieve obstruction using stent (in the case of stricture)

can do this via ERCP

43
Q

how does ERCP work

A

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

44
Q

advantage of ERCP

A

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

45
Q

when is ERCP not therapeutic

A

not therapeutic for stones in the gall bladder or cystic duct

46
Q

risks of ERCP

A

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

47
Q

management and treatment of acute cholangitis

A

analgesia
antibiotics
antiemetics
fluid balance (IV and urinary catheter)
venous thromboembolism prophylaxis
NBM (in preparation for ERCP)

48
Q

which blood result is most useful to diagnose ERCP-induced pancreatitis

A

lipase

49
Q

how would you treat acute pancreatitis secondary to ERCP

A

analgesia
antiemetics
no antibiotics (however patient will be on then if have cholangitis)
fluid balance (IV fluids and urinary catheter)
venous thromboembolism prophylaxis

50
Q

biliary colic vs cholecystitis vs cholangitis

A

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

Semester 1 ( 3rd Year) (12 decks)

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