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Gallstones and Gall Bladder > Cholecystitis > Flashcards

Cholecystitis Flashcards

1
Q

which part of the gall bladder is the most sensitive to ischemia following acute cholecystitis ?

OR

Which is the most common location for necrosis in GB

A. Neck
B. Infundibulum
C. Fundus
D. Body

A

Ans C - Fundus -

fundus of the GB is at the greatest distance from the cystic arterial blood supply and therefore more sensitive to ischemia.

Blumgart 6e Pg 556

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2
Q

what percentage of bile cultures are found positive in acute cholecystitis?

A. 10%
B. 20%
C. 30%
D. 70%

A

Ans B -
Positive bile cultures are found in approximately 20% patients in acute cholecystitis due to secondary biliary infection.

Blumgart 6e Pg 557

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3
Q

What percentage of patients have bactobilia after endoscopic sphincterotomy or biliary instrumentation?

A. 10%
B. 20%
C. 40%
D. 60%

A

ans D -

nearly 60% patients may have bactobilia after instrumentation or endoscopic sphincterotomy

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4
Q

Which is the most common organism isolated from bile cultures in acute cholecystitis?

A. Klebsiella
B. Pseudomonas
C. Peptostreptococcus
D. Staph Aureus

A

Ans A - Klebsiella.

Most common organisms are the gram negative bacteria of GI origin.

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5
Q

Which of the following is a finding not seen in biliary colic?

A. self limited intermittent
B. Radiation to the sub-scapular area
C. pain located in RUQ or Epigastric region
D. Fever and Leukocytosis

A

Ans D

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6
Q

Which of following is not a typical sonographic finding of acute cholecystitis?

A. Wall thickening > 1mm
B. Pericholecystic Fluid
C. Gallstones
D. sonographic Murphy sign

A

Ans A :

Wall thickening is defined as thickness of 4mm or more.

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7
Q

what is the definition of abnormal emptying of GB on HIDA scan?

A. EF < 35%
B. EF < 50%
C. EF < 70%
D. EF < 85%

A

Ans - A
Ejection fraction less than 35% is defined as abnormal emptying.

Middleton and William reported on 141 patients with normal USG and normal filling of GB on HIDA. But with EF < 35%. Of these patients 95% had significant improvement of symptoms after cholecystectomy, and 40% of them were found to have cholecystitis on HPE.

Blumgart 6e Pg 556.

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8
Q

which of the following is a finding of Acute cholecystitis on CT abdomen?

A. Contracted Gall Bladder
B. Low attenuation Bile
C. Pericholecystic stranding
D. Sub-mucosal edema.

A

Ans C -

CT signs of acute cholecystitis are -
Wall thickening, pericholecystic stranding, distended GB, High Attenuation Bile, Pericholecystic Fluid, Sub-serosal edema.

CT is less sensitive than USG for diagnosing acute cholecystitis, especially early in the course.

Non-filling of GB on HIDA is accurate in 90% of patients and may be more accurate than USG alone.

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9
Q

A patient presents with severe pain in upper abdomen associated with nausea and vomiting since 2 days. On examination tenderness was present in right hypochondrium. TLC 8800, ALP 23, AST 22 IU/L, ALT 21 IU/L. Ultrasound abdomen failed to show any gallstones.
What is the next line of investigation?

A. UGI endoscopy
B. HIDA
C. MRCP
D. CECT abdomen

A

Ans A Endoscopy

Blumgart 6e Pg 557
“Mahid and colleagues have suggested a diagnostic approach that starts with US for patients with biliary symptoms. If no gallstones are definitively identified, this would be followed by UGI endoscopy to exclude the alternate causes such as peptic ulcer disease or gastritis. If this test result is negative, hepatobiliary scintigraphy should follow”

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10
Q

which of the following is not a risk factor for the conversion to open cholecystectomy during lap cholecystectomy for acute cholecystitis?

A. Male Gender
B. Raised WBC counts
C. Obesity
D. Multiple calculi

A

Ans D - multiple calculi.

the risk for conversion to open is higher for patients undergoing lap cholecystectomy for acute cholecystitis compared to those undergoing elective cholecystectomy for simple biliary colic.

Most patients (>80%) can undergo laparoscopic cholecystectomy successfully.

Blumgart e6 Pg 558

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11
Q

which of the following is not a treatment option in patient with severe acute cholecystitis not responding to antibiotics with high perioperative risk in view of sepsis or medical comorbidities -

  1. Percutaneous cholecystostomy tube under USG guidance
  2. Percutaneous stone extraction
  3. Percutaneous transhepatic gallbladder aspiration
  4. Continue Conservative management followed by delayed cholecystectomy
A

Ans D - in a patient not responding to antibiotics with severe acute cholecystitis, the gall bladder must be decompressed using any of the three - A or B or C.

Blumgart 6e Pg 558

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12
Q

which of the following is FALSE regarding early cholecystectomy in acute cholecystitis?

A. early open cholecystectomy (<3days) not associated with increased operative mortality or morbidity

B. more than 20% patients do not respond to medical management while awaiting definitive treatment.

C. patients undergoing delayed treatment require overall prolonged hospitalization but shorter post-operative hospitalisation.

D. there is no difference in the mortality and morbidity for lap cholecystectomy performed for acute cholecystitis compared to biliary colic.

A

Ans D -

There is no difference in mortaltiy and morbidity including CBD injury in lap cholecystectomy performed for acute cholecystitis when performed early vs delayed.
There was also no difference in conversion to open in early vs late acute cholecystitis.

However the morbidity as well as the chances of conversion to open are increased when the results of laparoscopic cholecystectomy are compared for acute cholecystitis vs elective lap cholecystectomy for biliary colic.

Patients randomly assigned to late cholecystectomy did not respond to conservative management in 15-30% cases.

Statement C - Patients undergoing early cholecystectomy for acute cholecystitis do experience a longer postoperative hospitalisation but there is a decrease in overall length of hospital stay.

Blumgart e6 Pg 558-559.

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13
Q

which of the following statements is FALSE regarding early cholecystectomy for acute cholecystitis?

A. Majority of the trials define early cholecystectomy as within 72 hours of symptom onset.

B. Use of harmonic scalpel may decrease the conversion rate in acute cholecystitis

C. benefits of early cholecystectomy are limited to 7 days of symptom onset

D. early cholecystectomy is more cost effective because of reduced overall length of stay and avoidance of readmission

A

Ans C -

although most trials define early cholecystectomy as 3 days or less, but a prospective study assessing timing of surgery found no difference in
- conversion rate
- morbidity
- postoperative hospital stay
for cholecystectomy performed at <3 days or 4-7 days or >7 days of symptom onset.
Benefits of early cholecystectomy are not limited to patients who are seen within 72 hours of symptom onset.

statements A, B and D are true.

Blumgart 6e Pg 559.

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14
Q

which of the following statements is false ?

A. Pathologic changes of chronic inflammation can be found in obese women in the absence of gallstones, may be d/t increased cholesterol saturation of bile.

B. Xanthogranulomatous cholecystitis can be impossible to distinguish from GB Cancer

C. Serum CA 19-9 can definitively differentiate between xanthogranulomatous cholecystitis and GB cancer

D. asymmetric thickening of wall with presence of foamy histiocytes and acute and chronic inflammatory cells are features of xanthogranulomatous cholecystitis

A

Ans C - Serum CA 19-9 levels can be elevated in xanthogranulomatous cholecystitis.

Blumgart 6e Pg 559

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15
Q

what percentage of acute cholecystitis are acalculous ?

A. 5-15%
B. 15-20%
C. 20-30%
D. 30-45%

A

Ans - 5-15% cases of acute cholecystitis are acalculous.

Blumgart 6e Pg 560.

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16
Q

which of the following statements is FALSE regarding acalculous cholecystitis?

A. patients with trauma, severe sepsis, burns or recovering from major operations are at risk

B. more common in females

C. ischemia, biliary stasis and sepsis and sludge seem to play some causative role.

D. increasing number of patients with atherosclerotic vascular disease related to DM and HTN are presenting with acalculous cholecystitis in OPD

A

Ans B -
Acalculous cholecystitis is more common in males unlike Acute Calculous cholecystitis which is more common in females.

Blumgart 6e Pg 560.

17
Q

Which of the following is not a risk factor associated with increased risk of acalculous cholecystitis in trauma patients

A. high injury severity score
B. Increased temperature
C. Increased Heart Rate
D. Transfusion requirement

A

Ans - B -

A, C and D are associated with high risk of acalculous cholecystitis in trauma patients.

ISS more than or equal to 12, requiring intensive care for more than 4 days was associated with an incidence of 11% for acalculous cholecystitis.

18
Q

Choose the false statement -

A. the diagnosis of acalculous cholecystitis is easier in the outpatient population as compared to critically ill.

B. incidence of gangrene and perforation of GB is increased in calculous cholecystitis compared to acalculous cholecystitis

C. mortality rates for acalculous cholecystitis can be as high as 15%

D. severe complications of acalculous cholecystitis are more common in elderly population.

A

Ans B

Statement A - True
the diagnosis is more straightforward in outpatient population where the condition is similar to caculous cholecystitis in presentation with fever, RUQ pain, leukocytosis and raised Bilirubin.
All of these findings are however non-specific in setting of sepsis and critical illness thus making diagnosis difficult in acutely ill patients.

Statement B - False
Incidence of gangrene and perforation and empyema of GB is higher in acalculous cholecystitis due to delay in diagnosis

Statement C - true

Statement D - true - Especially in elderly with raised WBC counts, may be a result of disturbance in capillary microcirculation.

19
Q

initial imaging test for patients suspected to have acalculous cholecystitis

A. USG abdomen
B. MRCP
C. CECT abdomen
D. HIDA scan

A

Ans - A - USG abdomen is the initial imaging test.

it will show -

  • thickened gall bladder wall
  • biliary sludge without stones.

Problem - findings are present in many critically ill patients especially those dependent on parenteral nutrition.

USG findings + Clinical symptoms (Pain/Distension/both, hemodynamic instability, organ failure) = all patients had acalculous cholecysititis on HPE.

USG findings but no major clinical symptoms - all USG findings returned to normal within 3 weeks.

20
Q

the specificity of HIDA scan in acute cholecystitis can be improved by adding?

A. Moprhine
B. Glucagon
C. CCK
D. Buscopan

A

Ans A -

Morphine can cause constriction of sphincter of Oddi and improve gall bladder filling.
This decreases the false positives and improves specificity but does not increase sensitivity of HIDA scan for acalculous cholecystitis.

21
Q

which of the following statements is true ?

A. Laparoscopic cholecystectomy is contraindicated in Acalculous cholecystitis

B. Percutaneous cholecystostomy must always be followed by cholecystectomy in cases of acalculous cholecystitis

C. gangrenous cholecystitis is more common in diabetics with acute cholecystitis who present with Ac. Cholecystitis

D. Investigation of choice in patients with gangrenous cholecystitis is USG

A

Ans C is true.

A. Laparoscopic cholecystectomy can be performed in most cases of acalculous cholecystitis.

B. Percutaneous cholecystostomy need not be followed by cholecystectomy in all cases of acalculous cholecystitis since it may even be definitive procedure because there is no obstruction.

D. Investigation of choice is CT.

Blumgart 6e pg 561

22
Q

findings most specific for gangrenous cholecystitis on CT scan are all except

A. air in the wall or lumen
B. Intraluminal membranes
C. irregular wall
D. Pericholecystic abscess
E. lack of mural enhancement on contrast
F. thickness of wall >4mm
A

ans F -

A, B, C, D and E are all findings associated with gangrenous cholecystitis on CT.

wall thickness is also seen increased in Ac. Cholecystitis.

Blumgart 6e Pg562.

23
Q

Percutaneous cholecystostomy is not a treatment option for which of the following?

A. Empyema GB
B. Acute Cholecystitis
C. Acalculous Cholecystitis
D. Emphysematous cholecysititis

A

D. Emphysematous cholecystitis is caused by gas forming bacteria. It is more common in men and patients with diabetes.
Treatment is IV antibiotics with coverage for Clostridium and followed by Emergent Cholecystectomy.

Blumgart 6e Pg 562.

24
Q

Laparoscopic cholecystectomy is not recommended in which of the following ?

A. Acalculous cholecystitis
B. Acute Cholecystitis
C. Mirrizzi syndrome
D. All of the above

A

Ans C - Mirrizzi Syndrome

Laparoscopic cholecystectomy is associated with increased rate of conversion and complications and not recommended.

GOLD STANDARD TREATMENT FOR MIRRIZZI SD. - OPEN CHOLECYSTECTOMY

Blumgart 6e Pg 563.

25
Q

which of the following is the preferred route for percutaneous cholecystostomy?

A. Transhepatic tract
B. Transperitoneal tract

A

Ans - A transhepatic tract is the preferred route -

  • matures faster - transhepatic tract matures in 2 weeks compared to 3 weeks for transperitoneal
  • faster removal of transhepatic drain
  • reduced incidence of bile leaks and bile peritonitis with transhepatic route.
  • avoids the peritoneum is patients with significant ascites and bowel interposition.

Blumgart 6e pg 568.

26
Q

Which of the following is increased risk with transhepatic tract compared to transperitoneal tract for percutaneous cholecystostomy?

A. Delayed removal of the drain
B. Bile leaks
C. Bowel Injury
D. Hemobilia

A

Ans D -

there is a potential for pneumothorax and hemobilia with transhepatic route.

Blumgart 6e Pg 568.

27
Q

Transperitoneal and Transhepatic catheter tract for percutaneous cholecystostomy mature in ?

A. 3 weeks and 2 weeks
B. 3 months and 2 months
C. 2 weeks and 3 weeks
D. 2 months and 3 months

A

Ans A - 3weeks for transperitoneal and 2 weeks for transhepatic.

28
Q

A cholecystogram is usually obtained before catheter removal after an percutaneous cholecystostomy at ?

A. 3-6 weeks
B. Not necessary in cases with small bore catheter
C. Not necessary if cystic duct was patent at insertion
D. All of the above

A

Ans D - all of the above.

Blumgart 6e Pg 568.

29
Q

ESWL for clearing gallstones was limited to ?

A. Number of stones < 3
B. Size of stones < 2cm
C. Both of A and B
D. Number of stones >3 and Size of stones >2cm

A

Ans C - both A and B.

ESWL - was however associated with high recurrence rates of 70% at 6 years and needed multiple sessions and was therefore not cost effective.

Blumgart 6e Pg 568

30
Q

MTBE, is a cholesterol solvent, stands for ?

A. Methoxy-Tert-Butyl-Ether
B. Methyl-Tert-Butyl-Ether
C. Methoxy-Terephthalate-Butyl Ether
D. Methyl-Terephthalate-Butyl Ether

A

Ans B - Methy-Tert-Butyl Ether.

However its use needs specialized tubings which will not be dissolved by MTBE and needs prolonged administration over many days. It is now of historical interest only.

Blumgart 6e Pg 568

Gallstones and Gall Bladder (3 decks)

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