Cholecystitis

Question 1

What is cholecystitis?

1 - inflammation of biliary tree
2 - presence of gallstones in gall bladder
3 - inflammation of gall bladder
4 - inflammation of ampulla of vatar

Answer 1

3 - inflammation of gall bladder

Question 2

What % of patients in the UK have cholecystitis?

1 - 0.5-1.5%
2 - 10-15%
3 - 20-30%
4 - >50%

Answer 2

2 - 10-15%

Question 3

Is cholecystitis more common in men or women?

Answer 3

• women x 3 likely up to age of 50

Question 4

What is the most common cause of cholecystitis?

1 - mucocoele
2 - dilated gall bladder walls
3 - liver injury
4 - obstruction of cystic duct due to gallstone

Answer 4

4 - obstruction of cystic duct due to gallstone

Question 5

In a patient with acute cholecystitis, which is often a surgical emergency, which of the following is NOT a common symptom of acute cholecystitis?

1 - severe right hypochondriac pain
2 - fever
3 - tachycardia
4 - pain worse following a meal
5 - palpable tender gall bladder
6 - pain worse on inspiration due to diaphragm pressing down

Answer 5

4 - pain worse following a meal

• differs from biliary colic as it lasts several days and can either get worse and need surgery or settle on its own

Question 6

In a patient with acute cholecystitis, Murphys sign can often be used. What is Murphys sign?

1 - painless jaundice with palpable gall bladder
2 - pain when not eating
3 - pain at tip of 9th rib
4 - pain with jaundice and palpable gall bladder

Answer 6

3 - pain at tip of 9th rib

• often used to describe as reduced respiration due to pain in right hypochondriac

Question 7

What is often the first line imaging method to identify a patient with acute cholecystitis?

1 - ultrasound
2 - CT scan
3 - MRI
4 - chest X-ray

Answer 7

1 - ultrasound

• can identify gallstones, thickened gall bladder wall, distended gall bladder, pericholcystic fluid (fluid surrounding gall bladder) and sonographic Murphys sign

Question 8

In patients presenting with acute cholecystitis and there has been no confirmation of infection, what are typically the first 2 lines of treatment?

1 - analgesics
2 - IV fluids
3 - antibiotics
4 - acute cholecystectomy

Answer 8

1 - analgesics
2 - IV fluids

• antibiotics are given when there is evidence the gall bladder is infected

Question 9

If a patient has acute cholecystitis, they will eventually need surgery at some stage. Although there is evidence that earlier surgery reduces complications of cholecystitis, this is not always possible. If the cholecystectomy can not be performed in 1 week, when should the surgery be peformed?

1 - as soon as possible
2 - <2 weeks
3 - >4 weeks
4 - >6 weeks

Answer 9

3 - >4 weeks

• this is from the point of diagnosis
• the delay is to allow the inflammation of the gall bladder settle

Question 10

If a patient has acute cholecystitis and their cholecystectomy is delayed there are complications. Which of the following is not typically a complication of acute cholecystitis?

1 - empyema
2 - gangrene
3 - fistula formation and gallstone ileus
4 - gastric outlet obstruction surgery

Answer 10

4 - gastric outlet obstruction surgery

• empyema is when the gall bladder fills with pus and becomes infected
• the most severe complication as untreated the gall bladder can perforate and cause generalised peritonitis

Question 11

If a patient has acute cholecystitis and their cholecystectomy is delayed there are complications, the main ones being empyema, gangrene and fistula formation that can cause a gallstone ileus. What leads to gangrene?

1 - common hepatic duct is blocked
2 - cystic ducts dilates and blocks cystic artery
3 - gall bladder distends and compresses blood vessels

Answer 11

3 - gall bladder distends and compresses blood vessels

• gall bladder distends, increases tension in the gallbladder wall, leading to inflammation and ischemic necrosis of the wall

Question 12

If a patient has acute cholecystitis and their cholecystectomy is delayed there are complications, the main ones being empyema, gangrene and fistula formation that can cause a gallstone ileus. Which of the following is NOT a sign of a cholecystoduodenal fistula and gallstone ileus?

1 - gas in biliary tree from duodenum
2 - intermittent pain with meals
3 - lack of pain as stone passes through fistula
4 - small bowel obstruction

Answer 12

2 - intermittent pain with meals

Question 13

If a patient has acute cholecystitis and their cholecystectomy is delayed there are complications, the main ones being empyema, gangrene and fistula formation that can cause a gallstone ileus. If a patient has a cholecystoduodenal fistula, this decompresses the biliary tree and a gallstone can pass into the small bowel. Where is this stone most likely to become lodged and cause a gallstone ileus?

1 - 3rd part of duodenum
2 - jejunum
3 - transverse colon
4 - terminal ileum

Answer 13

4 - terminal ileum

• narrowest part of the small bowel

Question 14

If a patient has a gallstone in the cystic duct or in the infundibulum (also called the Hartmanns pouch) of the gallbladder, this can become impacted and continue to grow leading to a blockage of the cystic duct and the common hepatic duct, which is called Mirizzi syndrome. Which of the following is NOT a common symptom of Mirizzi syndrome?

1 - jaundice
2 - fever
3 - palpable gall bladder
4 - right hypochondriac pain
5 - abnormal LFTs and dilated hepatic ducts

Answer 14

3 - palpable gall bladder

Question 15

If a patient has a gallstone in the cystic duct or in the infundibulum (also called the Hartmanns pouch) of the gallbladder, this can become impacted and continue to grow leading to a blockage of the cystic duct and the common hepatic duct, which is called Mirizzi syndrome. This can lead to jaundice, fever, right hypochondriac pain, abnormal LFTs and dilated hepatic ducts. How is this commonly diagnosed?

1 - ultrasound
2 - MRCP
3 - CT with contrast
4 - ERCP

Answer 15

2 - MRCP
4 - ERCP

Question 16

If a patient has a gallstone in the cystic duct or in the infundibulum (also called the Hartmanns pouch) of the gallbladder, this can become impacted and continue to grow leading to a blockage of the cystic duct and the common hepatic duct, which is called Mirizzi syndrome. This can lead to jaundice, fever, right hypochondriac pain, abnormal LFTs and dilated hepatic ducts. How is this commonly treated?

1 - laparoscopic cholecystectomy
2 - laparotomy cholecystectomy
3 - conservative management with analgesia and IV fluids
4 - analgesia, IV fluids and antibiotics

Answer 16

1 - laparoscopic cholecystectomy

Question 17

What is acute cholangitis?

1 - inflammation of biliary tree
2 - presence of gallstones in gall bladder
3 - inflammation of gall bladder
4 - inflammation of ampulla of vatar

Answer 17

1 - inflammation of biliary tree

• chol = bile
• ang = vessel
• itis = inflammation

Question 18

Where do the majority of gallstones form?

1 - cystic duct
2 - gall bladder
3 - common hepatic duct
4 - common bile duct

Answer 18

2 - gall bladder

Question 19

What is a bile duct stone?

1 - gallstone with high concentration of bile salts
2 - gallstone that blocks the gall bladder
3 - gallstone that leaves the gall bladder and blocks the biliary tree
4 - infected gall stone

Answer 19

3 - gallstone that leaves the gall bladder and blocks the biliary tree

Question 20

The narrowest part of the common bile duct is the lower end and this is the location where bile duct stones tend to collect. Here they can become impacted and causes an obstruction, which can lead to jaundice. Is this continuous and progressive jaundice?

Answer 20

• can be both
• gallstones can form ball valves and cause intermittent jaundice
• complete obstruction leads to progressive jaundice

Question 21

The narrowest part of the common bile duct is the lower end and this is the location where bile duct stones tend to collect. Here they can become impacted and causes an obstruction, which can lead to jaundice. What can then happen to the biliary tree?

1 - perforates
2 - dilates
3 - fistulas form
4 - abscess forms

Answer 21

2 - dilates

• even if obstruction is removed the biliary tree may not return to normal, leading to stasis of bile and increased risk of bile stones
• gall bladder rarely distends

Question 22

If there is an obstruction in the biliary tree due to bile duct stone this can lead to what?

1 - acute cholangitis (ascending)
2 - acute cholecystitis
3 - acute cholecystectomy
4 - acute cholecystokinin

Answer 22

1 - acute cholangitis (ascending)

Question 23

Acute ascending cholangitis is when there is an obstruction in the biliary tree due to bile duct stone. This can lead to what complication?

1 - further gallstones
2 - bacterial infection of the biliary tree
3 - carcinoma
4 - fistula

Answer 23

2 - bacterial infection of the biliary tree

• these patients are at a high risk for sepsis

Question 24

Acute ascending cholangitis is when there is an obstruction in the biliary tree due to bile duct stone that can lead to bacterial infection of the biliary tree and even sepsis. Charcots triad is used to identify patients with acute ascending cholangitis, which of the following is NOT part of this triad?

1 - intermittent right hypochondriac pain
2 - pyrexia
3 - jaundice
4 - palpable gall bladder

Answer 24

4 - palpable gall bladder

• weight loss is also common

Question 25

Indications for surgery include:

• symptomatic gallstone disease
• asymptomatic gallstone disease with high likelihood of complications

What is the gold standard for removal of the gall bladder?

1 - laparotomy cholecystectomy
2 - laparoscopic cholecystectomy
3 - ERCP
4 - MRCP

Answer 25

2 - laparoscopic cholecystectomy