CBL_gallbladder disease Flashcards
Cause of gallstone pancreatitis?
Gallstone pancreatitis most common cause of pancreatitis as stone stuck in Ampulla of Vater
What can be seen on USS for cholecystitis?
Gallstones, thickened gallbladder wall, pericholecystic fluids
What basic investigations a patient with RUQ pain should have
All patients should have
- Blood test
- X-rays
- ECG
Symptoms and signs of acute cholecystitis
- Sudden onset
- Post-prandial
- RUQ pain radiate to back
- Constant
- Associated with nausea and vomiting
- Recurrent attack common
- Pyrexia
- Murphy’s positive
- Jaundice – CBD stones or Mirrizi’s syndrome
Risk factors for gallstone disease
Gallstone disease
- F>M (2:1)
- Obesity (Fat, Female, Forty, Fair/white)
- Pregnancy
- Haemolytic anaemias (pigment stones)
- Genetic predisposition
What would be seen on USS of biliary tract with cholangitis?
Bile duct dilation
* normally it is less than 6mm
* greater diameter in the elderly and those who had a cholecystectomy
* gallstones (underlying cause) may also be present
What happens in biliary colic? (anatomically/ pathologically)
Biliary colic - contraction of the gallbladder against a blocked cystic duct
What is cholangitis?
Common causes
Cholangitis - infection of the biliary tract (biliary tract obstruction + infection)
Common cause: gallstone obstruction + biliary stasis -> prone to bacterial cononisation
*less common causes: ERCP, cholangiocarcinoma
Bile components
- Bilirubin (by-product of haeme degradation)
- Cholesterol (kept soluble by bile salts and lecithin)
- Bile salts (cholic acid/chenodeoxycholic acid: mostly reabsorbed in terminal ileum)
- Lecithin (increase solubility of cholesterol)
- Inorganic salts (sodium bicarbonate to keep bile alkaline to neutralise gastric acid in duodenum)
- Water (97% of bile)
Blood tests for cholangitis
- FBC -> leucocytosis is often found
- LFTs -> raised ALP ± GGT with a raised bilirubin
- Blood cultures -> only being positive in 20% of cases (but need to always take)
*The best opportunity to obtain a positive blood culture is early, before the start of broad spectrum antibiotics
What causes gallstones
•Imbalance in the chemical make-up of bile inside gall bladder
–Bile contains too much cholesterol
–Bile contains too much bilirubin
–GB doesn’t empty
What do we do if a patient needs to undergo cholecystectomy but is unfit for the surgery? (as in acute cholecystitis)
If unfit for the surgery and antibiotics did not help:
Percutaneous cholecystostomy can be performed to drain the infection, with the patient advised regarding further lifestyle changes thereafter
(as the gallstones remain in-situ, the risk of recurring disease remains).
What elements of examination we need to consider while examining for a gallbladder pathology?
- signs of inflammation (e.g. tachycardia, pyrexia)
- signs of peritonitis or perforation
- signs of jaundice or hepatomegaly
- acute cholecystitis -> tender in the RUQ and will likely demonstrate a positive Murphy’s sign
Laboratory tests in biliary colic/acute cholecystitis presentation + rationale
Urinalysis (including a pregnancy test if female) should be performed to exclude any renal and tubo-ovarian pathology
Routine blood tests should be ordered:
- FBC and CRP – assess for the presence of any inflammatory response, which will be raised in biliary pathology such as cholecystitis, cholangitis, and pancreatitis
- U&Es – assess for any dehydration, secondary to reduced oral fluid intake (as certain foods can worsen the pain)
- LFTs – biliary colic and acute cholecystitis are likely to show a raised ALP (indicating ductal occlusion), yet the other parameters should remain within normal ranges
- Amylase – to check for pancreatitis
Gallbladder empyema
- what is this/ what happens
- clinical presentation
- investigations
- treatment
Gallbladder empyema
Pathology: gallbladder is infected and an abscess forms within the gallbladder
Presentation: typically septic, similar to acute cholecystitis (RUQ constant pain, fever, vomiting, nausea, abdominal distention, anorexia)
Investigations: USS, CT
Treatment:
-laparoscopic cholecystectomy (may require intra-operative drainage if tense gallbladder)
-percutaneous cholecystostomy (if unsuitable for surgery)
What’s Charcot’s Triad?
What’s Reynold’s pentad?
Charcot’s tirad: fever, jaundice, RUQ pain
Reynold’s pentad: fever, jaundice, RUQ pain, confusion, hypotension
USS for cholecystitis
How (in terms of clinical presentation) biliary colic and cholecystitis are different from cholangitis?
- Biliarycolic will present with a colicky RUQ pain yet without fever, leucocytosis, or jaundice.
- Cholecystitis will present with RUQ pain and fever yet jaundice will be absent
Ascending cholangitis
- history
- examination
- blood tests + results
Ascending Cholangitis
Characteristics of colicky pain - in terms of relief (time and reason)
- Typically colicky pain resolve after minutes to few hours
- Pain relieved when stone re-enters gallbladder or is passed through the duct into the small bowel
What other diseases are gallstones associated with?
Associated with
- Crohn’s disease
- Diabetes
- Hypertriglyceridaemia
- partial gastrectomy
Definitive management of cholangitis
- endoscopic biliary decompression -> to remove cause of obstruction to biliary tree
- ERCP (with or without sphinctrotomy + senting) -> to remove any obstruction of the biliary tree
*if a patient cannot tolerate surgery - then do percutaneous transhepatic cholangiography (PTC)
Long term:
- identify the cause for cholangitis
- cholecystectomy - if the cause of cholangitis was the obstruction by a gallstone
Complications of acute cholecystitis
Complications of acute cholecystitis
–Empyema - collection of pus in the gallbladder
–septicaemia
–chronic cholecystitis
–perforation of gallbladder
Acute cholangitis
- what’s that
- cause
- symptoms
Acute cholangitis : severe infection of biliary tree
Symptoms: fever, pain and jaundice
Cause: a stone in common bile duct or a stricture or after ERCP (1%)
Chronic cholecystitis
- pathology (what happens)
- possible complications
- clinical presentation
- diagnosis
- management
Chronic cholecystitis
Pathology: recurrent or untreated cholecystitis -> chronic inflammation of the gallbladder wall
Possible complications: Its main complications are increased risk of gallbladder carcinoma and biliary-enteric fistula
Presentation: may be asymptomatic or present with ongoing RUQ or epigastric pain with associated nausea and vomiting.
Diagnosis: CT scan (or often noted on histology post-cholecystectomy).
Management: elective cholecystectomy
Initial management of biliary colic
* what if the symptoms would not improve
Medications:
- prescribed analgesia (typically NSAIDs and PRN opioids)
- an appropriate antiemetic
if there is no improvement in symptoms with analgesia, consider a potential cholecystitis picture
Lifestyle advice:
lifestyle factors that may help control symptoms (and help with future surgery), such as a low fat diet, weight loss, increasing exercise, and provided with suitable analgesia at discharge
Acute pancreatitis
- history
- exam
- blood results + findings
Types of cholecystectomy
- Majority done using Minimal access surgery (95%)
- Open cholecystectomy less common
What are the two most common presentations of gallstones?
- Biliary colic is the most common presentation
- 2nd most common presentation is acute cholecystitis
What’s a gold standard investigation (imaging) for cholangitis?
ERCP
- it is for investigation but also be a therapeutic mode
Prognosis for a patient with biliary colic. What need to tell them
Following first presentation of biliary colic, there is a high chance of symptom recurrence or the development of complications of gallstones for example cholecystitis, or acute pancreatitis
Therefore an elective cholecystectomy may be needed
Bouveret’s syndrome and gallstone ileus
- what they are / why they happen
- what is Bouveret
- what us gallstone ileus
Bouveret’s Syndrome and Gallstone Ileus
Inflammation of the gallbladder (typically if recurrent or silent) can cause a fistula to form between the gallbladder wall and the duodenum, allowing gallstones to pass into the small bowel. As a consequence, bowel obstruction can occur:
- Bouveret’s Syndrome – stone impacts to cause duodenal obstruction
- Gallstone Ileus – stone impacts to cause an obstruction at the terminal ileum (the narrowest part of the adult bowel)
Definitive management of acute cholecystitis
A laparoscopic cholecystectomy is indicated within 1 week (NICE), however this ideally should be done within 72hr of presentation
Definitive management of biliary colic
Elective cholecystectomy or a surgical clinic review for consideration for a cholecystectomy (in a patient presenting with biliary colic
*should ideally be offered within 6 weeks of first presentation
- The laparoscopic route is preferred for cholecystectomy but is not always possible.
Is there inflammation in biliary colic?
No
Biliary colic occurs when the gallbladder neck becomes impacted by a gallstone. There is no inflammatory response, yet the contraction of the gallbladder against the occluded neck will result in pain
The most common bacteria involved in cholangitis?
Escherichia Coli (27%)
Klebsiella species (16%)
Enterococcus (15%)
What do we need to exclude if a patient is admitted with RUQ pain post-cholecystectomy?
- Important to exclude a retained CBD stone post-operatively
- US abdomen scan may be useful, yet if this is unremarkable, then further investigation via MRCP imaging
Contraindications to ERCP
Contraindications to ERCP:
- Hypersensitivity to iodinated contrast medium
- History of iodinated contrast dye anaphylaxis (although iodine-free contrast is now available)
- Acute pancreatitis (unless persistently elevated or rising bilirubin suggests ongoing obstruction)
- (Irreversible) coagulation disorder if sphincterotomy planned
- Recent myocardial infarction or pulmonary embolism
- Severe cardiopulmonary disease or other serious morbidity
Types of gallstones
Types of Gallstones:
–Cholesterol stones (80%)
–Pigment stones
–Mixed stones
Acute cholecystitis - how to differentiate between biliary colic
The symptoms of acute cholecystitis are often similar to that of someone with biliary colic, although, with acute cholecystitis:
- the pain may be constant, persistent despite pain relief,
- often associated with signs of inflammation (e.g fever, raised WCC).
- some derangement of their LFTs
*whereas in biliary colic: the pain will often be relieved with analgesia and will be colicky (comes and goes), no inflammation
What’s gangrenous cholecystitis?
- what is this
- pathophysiology
Gangrenous cholecystitis (GC) is a rare but serious complication of acute cholecystitis.
Pathophysiology:
secondary to gallbladder distension, causing increased tension and pressure on the gallbladder wall. This distension later leads to ischemic changes and necrosis of the gallbladder.
Immediate management of cholangitis
The patient may present with sepsis or develop sepsis, therefore:
- gain IV access
- fluid resuscitation
- routine bloods
- blood cultures
- broad broad-spectrum antibiotics (metronidazole + co-amoxiclav)
*management in higher level of care
What’s biliary colic?
Pain associated with passage of stone
(a stone tries to get through the muscular/smooth muscle tube)
What are the diagnostic imaging modes used to recognise perforated gallbladder?
Abdominal USS and abdominal CT
Biliary colic
- history
- examination
- blood tests + results
Biliary colic
Advantages and disadvantages of minimal access surgery
Advantages
–Less pain
–Shorter hospital stay
–Quicker return to normal activities
Disadvantages
–Learning curve
–Slightly more complication
What’s gallstone ileus?
How common is it?
Gallstone ileus due to bowel occlusion by gallstones
- rare about 2% of bowel obstruction
Possible complications of biliary colic and acute cholecystitis
(just name them, do not explain)
- gallbladder empyema
- chronic cholecystitis
- gallstone ileus
- Bouveret’s syndrome
- obstructive jaundice
- ascending cholangitis
- cute pancreatitis.
Initial management of Acute Cholecystitis
Initial Management
- appropriate intravenous antibiotics (such as co-amoxiclav +/- metronidazole)
- fluid resuscitation therapy
- If the patient demonstrates evidence of sepsis, management should be adapted accordingly
- Concurrent analgesia, typically simple analgesics with PRN opioids, and antiemetics should be prescribed
*Ideally, an NG tube should be placed if the patient is vomiting and the patient made nil by mouth (NBM), as an ultrasound is more sensitive in the absence (or reduction) of bowel gas
Causes of RUQ pain
- Gallstones disease (and its related complications)
- Gastritis/duodenitis
- Peptic ulcer disease/perforated peptic ulcer
- Acute pancreatitis
- Right Lower lobe pneumonia
- MI
Acute cholecystitis
- history
- examination
- blood tests + results
Acute cholecystitis
What’s acute cholecystitis?
Causes of it
Acute Cholecystitis -> acute inflammation of the gallbladder
- Gallstone stuck in cystic duct
- Less commonly with biliary sludge/precipitate
- A-calculus (no stones) cholecystitis rare
- Bacterial infection in 50% only
Which of the following lab value abnormalities suggests common bile duct obstruction in cholecystitis?
Elevated bilirubin
Management of biliary colic
- Usually resolve itself
- Analgesia
- Fluid if vomiting
- Anti-emetics
- Exclude acute cholecystitis
- Bloods: LFTs, FBC, U+Es
- Ultrasound
- Elective Cholecystectomy
First line imaging for gallstone pathology + what to look for
Abdominal USS
*only 50% sensitivity -> do MRCP if inconclusive
Look for:
- wall thickness of the gallbladder -> may be thickened in inflammation
- presence of gallstones or precipitate/ sludge (may be at the beginning of gallstone formation)
- bile duct dilation -> indicate a presence of gallstone/ obstruction/stricture in a distal bile duct
Name parts of anatomy of bile duct
Who should undergo MRCP?
Any patient with symptoms suggestive of gallstones with inconclusive US (or CT scans) should undergo a MRCP
How common gallbladder problems are in the UK?
- 1 in every 10 adults in the UK has Gallstones
- Only minority develop symptoms
- 80% of stones asymptomatic
- 20% develop symptoms or complication related to gallstones
Obstructive jaundice
- history
- examination
- blood tests + results
Obstructive jaundice
What organisms may cause acute cholangitis?
- Usual bugs are Klebsiella, E.Coli, Enterococci, streptococci in UK
- parasites in other countries might be roundworm and liver fluke
Complications of ERCP
- repeated cholangitis
- pancreatitis (in 3-5% of patients),
- bleeding (more common when a sphincterotomy is performed),
- perforation (a rare complication yet requires urgent surgical intervention if present)
What’s Murphy’s sign?
- disease associated with
- describe
What is a gallbladder perforation? What may it lead to?
Gallbladder perforation is rare, life-threatening complication of acute cholecystitis
- may lead to peritonitis and extra-hepatic abscess
Imaging in the investigation for cholangitis
(only name the modes)
- USS
- ERCP
What’s the most common underlying cause of the stones:
- cholesterol
- pigment
- mixed
•Cholesterol
–Imbalance between bile salts/lecithin and cholesterol allows cholesterol to precipitate
•Pigment
–Due to excess circulating bile pigments (haemolytic anaemia)
•Mixed
–Same as cholesterol stone
What’s the gold standard imaging for gallstones?
Magnetic Resonance Cholangiopancreatography (MRCP)
- largely replacing ERCP for diagnostic purposes
- MRCP can show potential defects in the biliary tree caused by gallstone disease - sensitivity approaching 100%
Gallstone ileus
- history
- examination
Therapeutic use of ERCP
ERCP - therapeutic use:
- Endoscopic sphincterotomy (of the biliary or the pancreatic duct sphincter)
- Removal of stones or other biliary debris
- Insertion of bile duct stent(s)
- Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after liver transplantation)<a>[</a>
Symptoms of biliary colic
- Sudden onset epigastrium or RUQ with radiates to Right shoulder or back
- Nausea or vomiting
- Sweaty
Other factors contributing to gallstones formation (3)
Other factors
–Stasis (pregnancy)
–Obesity and hypercholesterolaemia
–Small bowel resection - imbalance of bile reabsorption
Management/investigations for acute cholecystitis
- Need admission
- Analgesia, DVT prophylaxis
- Intravenous fluids
- Bloods
- Ultrasound to confirm diagnosis
- Gallstones, thickened gallbladder wall, pericholecystic fluids)
- Antibiotics
- Majority (95%) resolve with conservative treatment
- May require CT scan to exclude complication
- Empyema (percutaneous drainage)
- Gangrene/perforation (Emergency surgery)
Empyema (gallbladder)
- history
- examination
- blood tests + results
Gallbladder emoyema
Why oral contraceptives increase the risk of gallstones?
Oestrogen causes more cholesterol being secreted into the bile
