Cholecystitis

Question 1

What is cholecystitis?

Answer 1

Inflamm of gall bladder, secondary to gall stones

Question 2

What are the components of bile? (3 things)

Answer 2

1. Cholesterol
2. Bile pigments (from broken down Hb)
3. Phospholipids

Question 3

What causes gall stones to form?

Answer 3

Change in concentration of the 3 bile components

Question 4

How do Pigment stones form?

Answer 4

Haemolysis (increased Bile pigments)

Question 5

What are the characteristics of Pigment stones? (3 things)

Answer 5

1. Small
2. Irregular
3. Friable

Question 6

How do Cholesterol stones form?

Answer 6

1. High cholesterol (obv)
2. Reduced bile salts
3. Reduced lecithin

(Admirand’s triangle)

Question 7

What increases the risk of Cholesterol stones to form?

Answer 7

1. Female
2. Age
3. Obesity

Question 8

What are the characteristics of Cholesterol stones? (2 things)

Answer 8

1. Large

2. Often solitary

Question 9

What are Mixed stones made up of?

Answer 9

1. Calcium salts
2. Pigment
3. Cholesterol

Question 10

What groups of people are Pigment stones more commonly seen in?

Why

Answer 10

Ppl with haemolytic anaemia

Bc increased bile pigment from Hb breakdown

Question 11

What are cholesterol stones made up of?

Answer 11

Purely cholesterol

Question 12

What are pigment stones made up of?

Answer 12

Purely bile pigment

Question 13

What are the risk factors for gall stones? (5 things)

Answer 13

1. Fat
2. Female
3. Fertile
4. Forty
5. FHx

5 F’s

Question 14

What are some other risk factors for gall stones? (4 things)

Answer 14

1. Pregnancy
2. COCP
3. Haemolytic anaemia
4. Malabsorption

Question 15

How can COCP cause gall stones?

Answer 15

Oestrogen causes more cholesterol to be secreted into bile

Question 16

What are the clinical features of Acute Cholecystitis?

Answer 16

1. Constant RUQ / epigastric pain
2. Fever
3. Murphy’s sign @ examination
4. Guarding = GB perforation

Question 17

Where does the RUQ pain of Acute Cholecystitis refer to?

Answer 17

Right shoulder

Question 18

What is the difference in clinical features between biliary colic and Acute Cholecystitis?

Answer 18

Inflammatory component (local peritonism / fever / increased WBC)

Question 19

What happens when the gall stones move to the Common Bile Duct (CBD) ?

Answer 19

1. Obstructive jaundice

2. Cholangitis

Question 20

What is Murphy’s Sign?

Answer 20

1. Apply pressure with 2 fingers @ RUQ
2. Ask patient to inspire
3. Positive Murphy’s Sign = halt in inspiration bc pain = inflamed GB

Team GB Andy Murray aka Murphy

Question 21

What are other differentials that present with RUQ pain when suspecting Acute Cholecystitis? (4 things)

Answer 21

1. GORD
2. Peptic Ulcer Disease (PUD)
3. Acute Pancreatitis
4. IBD

Question 22

What lab tests should be done for suspected Acute Cholecystitis?

Answer 22

1. FBC
2. CRP
3. LFT
4. Amylase (or lipase)
5. Urinalysis (+ pregnancy test if relevant)

Question 23

Why should FBC and CRP be done for suspected Acute Cholecystitis?

Answer 23

To assess for presence of inflammatory response

High WBC + CRP

Question 24

Why should LFT’s be done for suspected Acute Cholecystitis? (2 things)

Answer 24

High LFT’s (e.g Bilirubin) = Duct occlusion

Question 25

Why should Amylase (or lipase) test be done for suspected Acute Cholecystitis?

Answer 25

To check for evidence of pancreatitis

Question 26

Why should Urinalysis (+ pregnancy test if relevant) be done for suspected Acute Cholecystitis?

Answer 26

To exclude renal / tubo-ovarian pathology

Question 27

What is the first line imaging technique for Acute Cholecystitis?

Answer 27

Trans-abdominal US

Question 28

What can be visualised on an US in Acute Cholecystitis? (4 things)

Answer 28

1. Presence of gallstones / sludge (start of gallstone formation) 2. GB wall thickness (thick = inflamm. likely) 3. Shrunken GB 4. Bile duct dilatation ( = possible stone in distal bile ducts)

Question 29

What scan should be done if US for Acute Cholecystitis is inconclusive? What does it show?

Answer 29

MRCP Shows defects in biliary tree

Question 30

How should a patient with Acute Cholecystitis be managed? (4 things)

Answer 30

1. IV abx (co-amoxiclav +/- metronidazole) 2. Analgesia 3. Anti-emetics 4. Laparoscopic cholecystectomy within 1 week (if fit 4 surgery)

Question 31

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?

Answer 31

Percutaneous cholecystostomy --> drain infection Gall stones still remain inside so still risk of recurring disease

Question 32

What are the complications of Acute Cholecystitis? (4 things)

Answer 32

1. Gangrenous Cholecystitis (20%) 2. Perforation (10%) 3. Gallbladder empyema 4. Cholecystoenteric Fistula (usually seen with Chronic cholecystitis)

Question 33

What does a Cholecystoenteric Fistula result in?

Answer 33

Air in biliary tree (pneumobilia)

Question 34

What happens if a gall stone passes through a Cholecystoenteric Fistula?

Answer 34

Results in gall stone ileus (narrowing??)