Case Nine - Acute cholecystitis Flashcards
what is acute cholecystitis caused by
a blockage in the cystic duct or neck of the gallbladder (95% of the cases are gallstones or sludge)
what can the obstruction cause
increase in mucus secretions from the gallbladder which causes gallbladder distension, and may affect the blood supply to the gallbladder
what is often the initial event in cholecystitis
often an obstruction to gallbladder emptying
in 95% of the cases, a gallstone is the cause. it is different to biliary colic because it is not a problem in the bile duct, but a problem in the gallbladder or in the cystic duct
what are the two effects of distension of the bile ducts
obstruction of blood flow to the gallbladder, as well as initiating an inflammatory response to the bile retained in the gallbladder
this can lead to mucosal damage, which in turn leads to the release of phospholipase,
what does phospholipase do
converts lecithin into lysolecithin which is a very potent toxin
what are the symptoms of acute cholecystitis and what are the y similar to
similar to biliary colic, and often differentiation is difficult
cholecystitis often results in a more prolonged pain with a fever and leukocytosis
what is Murphys sign
there will be RUQ pain
this is usually worse on inspiration. Murphy’s sign is where you would put your hand under the patient’s ribs and ask them to breathe in. As they do so, their gallbladder will be forced down against your hand, and it will cause them a lot of pain
when is Murphy’s sign only a positive result
only a positive result if the sign is negative in the LUQ
why does the pain radiate in acute cholecystitis and how does this differentiate
the pain is more likely to radiate to the shoulder tip in this than in other biliary conditions because the radiation is caused by irritation of the diaphragm and this is more likely in cholecystitis
what are the investigations carried out for acute cholecytsisis
FBC
serum amylase
serum bilirubin
USS
what would an FBC in acute cholecystitis show
raised ESR, CRP, WCC
what would a serum amylase show
increase as acute pancreatitis may be present as a compliation of gallstones
what would the USS detect
gallstones
gallbladder wall thickening
dilated common bile duct >6mm
what are the antibiotics given in acute cholecystitis
cefuroxime
metronidazole
what are the pain reliefs given in acute cholecysistis
usually diclofenac (NSAID) with pethidine (fast acting opioid) in more severe cases
what are the complications of acute cholecystitis
gangrene
bacterial infection and subsequent empyema
perforation
what is empyema
this is a collection of pus in the body cavity . it is different from an abcess, which is a colleciton of pus in a newly formed body cavity
what may be seen in patients with chronic cholecystisis
vague abdominal symptoms
sometimes associated with GI malignancy
what investigations are used to look for chronic cholecystitis
USS - evidence of gallstones and check common bile duct diameter
MRCP - may also be used to check for stones. In this procedure, MRI scanning is used to visualise the biliary tree. It is much less invasive than ERCP - which requires the insertion of dye into the biliary tree via OGD. ERCP has obvious therapeutic advantages that MRCP does not.
M,RCP is used to supplement USS
what is the treatment of chronic cholecystitis
ERCP - usually performed to remove any stones from the common bile duct and perform sphincterotomy before cholecystectomy
cholecystectomy - performed in troubling cases
what does the inflammatory response in acute cholecystitis cause
wall ischaemia and infection to ensue to cause localised peritonitis
what are the several modalities used to image a stone in the common bile duct
transabdominal ultrasound first line
MRCP
EUS
what is the gold standard for visualising stones in the CBD
endoscopic ultrasound (EUS)
why must any CBD stones causing obstructive jaundice be removed first prior to a laparoscopic cholecystectomy
a high biliary pressure from any obstruction can cause a bile leak from the cystic duct stump where the gallbladder is amputated during the cholecystectomy
what does a thickened wall gallbladder indicate
either acute or chronic inflammation of the gallbladder
what kind of finding is pericholecystic fluid
an acute finding
what is the intial treatment in AandE of acute cholecystitis
Initial treatment would include:
- Analgesia
- Antiemetics
- Antibiotics (according to hospital guidelines)
- Fluid balance (intravenous fluids)
- Venous thromboembolism prophylaxis
- Nil by mouth, in anticipation for surgery
what definitive management would you offer
laparoscopic cholecystectomy
surgery should be considered to remove the gallbladder on the same hospital admission (laparoscopic cholecystectomy)
what are the risks of laparoscopic cholecystectomy surgery
The general risks of surgery include bleeding, infection, pain, chest and urinary infections, deep vein thrombosis/pulmonary embolism and risks associated with general anaesthesia. Specifically for a laparoscopic cholecystectomy:
- Damage to the common bile duct
- Bile leak
- Damage to surrounding structures (such as the duodenum or stomach)
- Conversion from a laparoscopic procedure to an open procedure
what are the components of Charcot’s triad for diagnosing acute cholangitis
right upper quadrant pain
jaundice
pyrexia
what does Reynolds pentad include
it has the three components of Charcot’s - RUQ pain, jaundice and temp
but it also includes mental status alterations and sepsis
what does an obstructive pattern of jaundice to the LFT’s suggest
common bile duct obstruction
what is the definition of acute cholangitis
infection of the biliary tree caused by a downstream obstruction of the common bile duct
what are the causes of acute cholangitis
cholelithiasis (most common)
benign biliary structure
sclerosing cholangitis
malignant strictures
what are the risk factors for acute cholangitis
age
history of gallstones
previous biliary surgery that may lead to a narrowing of the bile duct
what investigations should be performed to investigate a suspected diagnosis of acute cholangitis
an urgent US of the abdomen should be performed to investigate the cause of the biliary obstruction
relieving the biliary obstruction will treat the cute cholangitis
what are the principles of treating a common bile duct obstruction
to either remove the cause or relieve the obstruction using a stent (in the case of a stricture)
this can be achieved endoscopically by an ERCP
what is an ERCP
endoscopic retrograde cholangiopancreatohraphy
it is an endoscopic procedure where a side viewing endoscope is used to identify and cannulate the ampulla of Vater which opens into the second part of the duodenum
a radio-opaque dye is then injected retrograde and passes up Into the CBD and the pancreatic duct
fluoroscopy are used to visualise the dye to detect any ‘filling defects’ that could indicate either a stone or a stricture
what is the advantage of an ERCP
that it can also be used to perform certain therapeutic procedures in the same procedure, such as extracting the stone using a wire basket, a sphincterterotomy of the sphincter of Oddi (to better allow the passage of bile) to to insert a stent across the obstruction to relieve the jaundice
what is ERCP NOT used for
a diagnostic procedure
first line is USS and MRCP to diagnose the cause of the biliary obstruction before an ERCP os performed
what are the risks of ERCP
acute pancreatitis (5%)
gastric/duodenal perforation
bleeding
risks associated with sedation
what is the initial treatment for acute cholangitis
Initial treatment would include:
● Analgesia
● Antiemetics
● Antibiotics (according to hospital guidelines)
● Fluid balance (intravenous fluids and urinary catheter)
● Venous thromboembolism prophylaxis
● Nil by mouth, in anticipation for an ERC
how would you treat acute pancreatitis after ERCP for acute cholangitis
analgesia
antiemetics
no antibiotics (still on these for cholangitis)
fluid balance
VTP
what is not a risk factor for developing gallstone disease
younger age
what condition is not associated with gallstone disease
peptic ulcer disease
what is Mirizzi’s syndrome
this is compression of the CBD from a gallstone in Hartmann’s pouch
A 35-year-old woman presents with intermittent right upper quadrant pain which lasts for a few hours each time she eats fatty foods. Bloods show a normal WCC and CRP, as well as normal LFTs and lipase. What is the most likely diagnosis?
biliary colic
A 78-year-old female presents with a 1-day history of confusion and ‘generally unwell’. She has a past medical history of hypertension and is known to have gallstones. Her observations are: BP 90/75, HR 120, RR 20 and a temperature of 38.9°C. On examination, she is visibly jaundiced, and she has guarding in her right upper quadrant. An urgent ultrasound scan shows a dilated common bile duct of 10mm with intrahepatic duct dilatation. After initial treatment of ABCDE, what is the definitive management of this patient?
ERCP
this is the most appropriate treatment to clear the CBD of obstructing stones to treat the acute cholangitis
what is pancreatitis
condition involving inflammation of the pancreas. it can be acute or chronic
what accounts for the vast majority of pancreatitis episodes
gallstones and alcohol
what is the pneumonic used to remember the causes of pancreatitis
GET SMASHED
what does each letter in GET SMASHED stand for
G – Gallstones
E – Ethanol (alcohol!)
T – Trauma
S – Steroids
M – Mumps
A – Autoimmune – e.g. SLE
S – Scorpion bites (rare!)
H – Hypercalcaemia, hypothermia, hyperlipiaemia
E – ERCP
D – Drugs – e.g. azathiaprin
what are the four steps of pathogenesis of pancreatitis
necrosis
autolysis
infection
pseudocyst
explain the pathogenesis of pancreatitis
- the final common pathway has marked increase in intracellular calcium which then leads to activation of intracellular proteases
- there is evidence that alcohol interferes with calcium homeostasis in pancreatic acinar cells
- in severe inflammation, it becomes swollen and haemorrhaic
- proteases digest the walls of the blood vessel which leads to blood extravasation
- amylase is release into the blood
- released lipase cause fat necrosis within the abdomen and subcutaneous tissue
what can the released lipase cause
discolouration of the skin - Grey Turner’s sign
what can the released fatty acids bind to and what does this lead to
bind to Ca2+ and this leads to Hypocalcaemia
what can concomitant destruction of adjacent islets do
lead to hyperglycaemia and thus can cause type II diabetes
what is pulmonary failure in acute pancreatitis believed to be caused by
circulating activated digestion enzymes
what are these digestion enzymes
trypsin, phospholipase A2 etc
what does this circulating level of activated digestion enzymes lead to
a loss of surfactant, atelectasis and irritation eventually leading to ARDS, and pleural effusion
what else can also occur in severe acute pancreatitis
cardiac depression and breakdown of the BBB
what are the clinical features of acute pancreatitis
upper abdominal pain, normally beginning in the epigastrium accompanied by nausea and vomiting
often radiates too the back
in severe cases of AP, what other symptoms can people have
tachycardia, hypotension and be oliguric
what would an abdominal examination show
widespread tenderness with guarding; also reduced/absent bowel sounds
what is Cullens sign
periumbilical bruising
what is Grey Turner’s sign
flank bruising
when are Cullens and turners signs present
in severe necrotiising pancratiits
what is indicative in poor prognosis
left sided pleural effusion
what will blood tests show in pancreatitis
raised serum amylase, lipase , also with raised urinary amylase
is amylase prognostic
no, nor is the level related to the degree of tissue damage
what is the most specific blood test for pancreatitis
lipase levels, and may relate to the level of tissue damage, but levels do not rise up until 8 hours after the onset of symptoms
what imaging is used to exclude gaastroduodenal perforation
CXR is used which also causes raised serum amylase
what is the treatment for pancreatitis
replace lost fluids
nasogastric suction to prevent abdominal distension and vomiting
analgesia - pethidine and tramadol
enteral nutrition
what are the three key cases of pancreatitis to remember
gallstones
alcohol
post-ERCP
how does alcohol cause pancreatitis
directly toxic to pancreatic cells, resulting in inflammation.
how much is amylase raised in pancreatitis
raised more than three times the upper limit of normal in acute pancreatitis
in chronic pancreatitis it may not rise because the pancreas has reduced function
what is the Glasgow score
used to assess the severity of pancreatitis. it gives a numerical score based on how many of the key criteria are present:
0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis
how can the criteria for the Glasgow score be remembered
using the PANCREAS pneumonic (1 point for each answer)
P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)
what may be required in chronic pancreatitis if there is loss of pancreatic enzymes
Creon
what are the two types of hiatus hernia
sliding hiatus hernia and rolling hiatus hernia
what is the most common type of hernia
sliding hiatus hernia. accounts for 95% of cases
what are they associated with
an increased incidence of GORD
what is a sliding hiatus hernia
when part of the stomach at the oesophageal gastric junction is pulled upwards through the diaphragm
this reduces the angle between the oesophagus and the stomach, and thus removes one of the natural anatomic barriers to reflux.
how is the sliding hiatus hernia covered
only by peritoneum on its lateral and anterior sides
the posterior is not covered due to the bare area on the back of the stomach
when does a rolling hiatus hernia occur
when part of the fundus of the stomach will extend through the diaphragm at a separate site to the oesophagus
they can sometimes be huge, with almost the whole stomach becoming herniated, leading the gastro-oesophageal function lying right alongside the pylorus
what is the rolling hiatus hernia surrounded by
completely surrounded by a peritoneal sac
what are the three key complications of hernias
Incarceration
Obstruction
Strangulation
what does Courvoisier’s law state
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
what are the features of carcinoid syndrome
abdominal pain
diarrhoea
flushing
releases serotonin into systematic circulation when there is metastasis to the liver
what is the AST/ALT ratio in alcoholic hepatitis
the ratio is 2:1
what diagnosis has a positive pANCA test
primary sclerosing cholangitis
what is upper GI bleeding
bleeding from the oesophagus, stomach or duodenu
what are the causes of upper GI bleeding
peptic ulcers
Mallory-Weiss tear
Oesophogeal Marikes
stomach cancers
what is a Mallory Weiss tear
a tear of the oesophagus mucosa
what is the presentation of upper GI bleeding
haematemesis (vomiting blood)
coffee ground vomit
melaena
what is the cause of coffee ground vomit
caused by vomiting digested blood with the appearance of coffee grounds
what does haemodynamic instability occur with
significant blood loss, causing low blood pressure, tachycardia, and other signs of shock
what are peptic ulcers associated with
history of epigastric pain and dyspepsia
they may be taking NSAIDS
when do Mallory Weiss tears occur
after heavy retching or vomiting, which may be caused by binge drinking, gastroenteritis, or hyperemesis gravidum
when does hyperemesis gravidarum occur
during early pregnancy
what are oesophageal varcices associated with
liver cirrhosis and portal hypertension
the patient will have signs of these conditions, such as ascites, jaundice and caput medusae
what is stomach cancer associated with
history of weight loss, epigastric pain, treatment resistant dyspepsia, low haemoglobin (anaemia) and a raised platelet count
what is the bleeding score used in the initial presentation of a suspected upper GI bleed
the Glasgow-Blatchford score
what does the Glasgow-Blatchford score do
estimates the risk of patient having an upper GI bleed
what score on the Glasgow Blatchford scale indicates high risk bleed
a score above 0 indicates a high risk for an Upper GI bleed
what factors does the Glasgow-Blatchford score take into account
Haemoglobin (falls in upper GI bleeding)
Urea (rises in upper GI bleeding)
Systolic blood pressure
Heart rate
Presence of melaena (black, tarry stools)
Syncope (loss of consciousness)
Liver disease
Heart failure
what is the association between an upper GI bleed and increased blood urea
acid and digestive enzymes break down blood in the upper GI tract.
one of the breakdown products is urea, which is then absorbed into the intestines, causing a rise in blood urea
what is the management of an upper GI bleed
the ABATED pneumonic
what does the ABATED pneumonic stand for
A – ABCDE approach to immediate resuscitation
B – Bloods
A – Access (ideally 2 x large bore cannula)
T – Transfusions are required
E – Endoscopy (within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs)
what do you send bloods for in suspected GI bleed
Haemoglobin (FBC)
Urea (U&Es)
Coagulation (INR and FBC for platelets)
Liver disease (LFTs)
Crossmatch 2 units of blood
what is group and save
when the lab checks the patient’s blood group and saves a blood sample to match blood if needed.
crossmatch is where the lab allocated units of blood, tests that it is compatible and keeps it ready in the fridge
when are blood, platelets and clotting factors given
to patients with a massive bleed
what is given in active bleeding
platelets are given in active bleeding plus thrombocytopenia (platelet count less than 50)
what is given to patients taking warfarin that are actively bleeding
prothrombin complex concentrate
what are the additional steps taken if oesophageal varies are suspected
terlipresisn
broad spectrum antibiotics
what is required to diagnose and treat the source of the bleeding
OGD
(endoscopy)
what do the NICE guidelines recommended against using until after Endoscopy in patients with non-varicial upper GI bleeding
recommend against using a proton pump inhibitor
