Cholecystitis Flashcards
What is cholecystitis?
Inflamm of gall bladder, secondary to gall stones
What are the components of bile? (3 things)
- Cholesterol
- Bile pigments (from broken down Hb)
- Phospholipids
What causes gall stones to form?
Change in concentration of the 3 bile components
How do Pigment stones form?
Haemolysis (increased Bile pigments)
What are the characteristics of Pigment stones? (3 things)
- Small
- Irregular
- Friable
How do Cholesterol stones form?
- High cholesterol (obv)
- Reduced bile salts
- Reduced lecithin
(Admirand’s triangle)
What increases the risk of Cholesterol stones to form?
- Female
- Age
- Obesity
What are the characteristics of Cholesterol stones? (2 things)
- Large
2. Often solitary
What are Mixed stones made up of?
- Calcium salts
- Pigment
- Cholesterol
What groups of people are Pigment stones more commonly seen in?
Why
Ppl with haemolytic anaemia
Bc increased bile pigment from Hb breakdown
What are cholesterol stones made up of?
Purely cholesterol
What are pigment stones made up of?
Purely bile pigment
What are the risk factors for gall stones? (5 things)
- Fat
- Female
- Fertile
- Forty
- FHx
5 F’s
What are some other risk factors for gall stones? (4 things)
- Pregnancy
- COCP
- Haemolytic anaemia
- Malabsorption
How can COCP cause gall stones?
Oestrogen causes more cholesterol to be secreted into bile
What are the clinical features of Acute Cholecystitis?
- Constant RUQ / epigastric pain
- Fever
- Murphy’s sign @ examination
- Guarding = GB perforation
Where does the RUQ pain of Acute Cholecystitis refer to?
Right shoulder
What is the difference in clinical features between biliary colic and Acute Cholecystitis?
Inflammatory component (local peritonism / fever / increased WBC)
What happens when the gall stones move to the Common Bile Duct (CBD) ?
- Obstructive jaundice
2. Cholangitis
What is Murphy’s Sign?
- Apply pressure with 2 fingers @ RUQ
- Ask patient to inspire
- Positive Murphy’s Sign = halt in inspiration bc pain = inflamed GB
Team GB Andy Murray aka Murphy
What are other differentials that present with RUQ pain when suspecting Acute Cholecystitis? (4 things)
- GORD
- Peptic Ulcer Disease (PUD)
- Acute Pancreatitis
- IBD
What lab tests should be done for suspected Acute Cholecystitis?
- FBC
- CRP
- LFT
- Amylase (or lipase)
- Urinalysis (+ pregnancy test if relevant)
Why should FBC and CRP be done for suspected Acute Cholecystitis?
To assess for presence of inflammatory response
High WBC + CRP
Why should LFT’s be done for suspected Acute Cholecystitis? (2 things)
High LFT’s (e.g Bilirubin) = Duct occlusion
Why should Amylase (or lipase) test be done for suspected Acute Cholecystitis?
To check for evidence of pancreatitis
Why should Urinalysis (+ pregnancy test if relevant) be done for suspected Acute Cholecystitis?
To exclude renal / tubo-ovarian pathology
What is the first line imaging technique for Acute Cholecystitis?
Trans-abdominal US
What can be visualised on an US in Acute Cholecystitis? (4 things)
- Presence of gallstones / sludge (start of gallstone formation)
- GB wall thickness (thick = inflamm. likely)
- Shrunken GB
- Bile duct dilatation ( = possible stone in distal bile ducts)
What scan should be done if US for Acute Cholecystitis is inconclusive?
What does it show?
MRCP
Shows defects in biliary tree
How should a patient with Acute Cholecystitis be managed? (4 things)
- IV abx (co-amoxiclav +/- metronidazole)
- Analgesia
- Anti-emetics
- Laparoscopic cholecystectomy within 1 week (if fit 4 surgery)
How can a patient with Acute Cholecystitis who is not fit for surgery and not responding to abx be managed?
Wbat is the down side to this?
Percutaneous cholecystostomy –> drain infection
Gall stones still remain inside so still risk of recurring disease
What are the complications of Acute Cholecystitis? (4 things)
- Gangrenous Cholecystitis (20%)
- Perforation (10%)
- Gallbladder empyema
- Cholecystoenteric Fistula (usually seen with Chronic cholecystitis)
What does a Cholecystoenteric Fistula result in?
Air in biliary tree (pneumobilia)
What happens if a gall stone passes through a Cholecystoenteric Fistula?
Results in gall stone ileus (narrowing??)
