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AIP: Abdominal pain > Cholecystitis > Flashcards

Cholecystitis Flashcards

1
Q

What are the technical terms used to describe gallstone disease?

A
  • cholelithiasis
  • choledocholithiasis: when stones are present in the bile ducts
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2
Q

How does most gallstone disease present and what causes it to vary?

A
  • mostly presents with acute + intermittent pain (epigastrium or right hypochondrium - RUQ)
  • less commonly with pain and jaundice - this is caused by a stone passing into and obstructing the common bile duct
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3
Q

What is the structure of the biliary system?

A
  • bile collects in canaliculi between hepatocytes, drains via collecting ducts within portal triads into system of ducts within the liver
  • progressively increase in diameter until become right + left hepatic ducts; fuse to form common hepatic duct
  • joined further distally by cystic duct to become the common bile duct
  • common bile duct 4-5cm long, passes behind duodenum then through head of pancreas to drain via ampulla of Vater into medial wall of 2nd part of duodenum (D2)
  • in most cases, main pancreatic duct joins the common bile duct at the ampulla, but may enter duodenum independently
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4
Q

What structure exists within the ampulla of Vater and what is its function?

A

sphincter of Oddi: prevents reflux of duodenal contents into the common bile duct and pancreatic duct

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5
Q

Where does the gallbladder lie?

A

in a variable depression in the undersurface of the right hepatic lobe; covered by the peritoneal envelope of the liver

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6
Q

What makes bile and what happens to it?

A

it is made continuously by the liver, passes along the biliary tract to the gallbladder where it is stored and concentrated (up to 10x) by process of active mucosal reabsorption of water

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7
Q

What causes contraction of the gallbladder?

A

lipid-rich food passing from stomach to duodenum promotes secretion of hormone cholecystokinin-pancrezymin by endocrine cells of duodenal mucosa

stimulates contraction of the gall bladder, squeezing bile into the duodenum

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8
Q

What is the role of bile salts (acids) in bile?

A

act as emulsifying agents, facilitate hydrolysis of dietary lipids by pancreatic lipases

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9
Q

What are the symptoms of biliary tract obstruction due to the reduced function of bile salts?

A

lipids neither digested nor absorbed, resulting in passage of loose, pale, foul-smelling fatty stools (steatorrhoea)

fat soluble vitamins (ADEK) not absorbed, lack of vitamin K soon leads to inadequate prothrombin synthesis and defective clotting (bleeding tendency)

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10
Q

Why can the inability to absorb fat-soluble vitamins in bile duct obstruction cause problems if surgery is necessary?

A

lack of vitamin K can cause defective clotting - may pose problems of haemostasis

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11
Q

What is the commonest type of gallstone in most developed countries and what is their composition?

A

mixed stones: predominance of cholesterol, plus bile pigment (calcium bilirubinate) and other calcium salts

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12
Q

What is the pathogenesis of mixed composition gallstones? 3 key things

A

combo of:

abnormalities of bile constituent concentrations + biliary stasis + infection

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13
Q

What are 5 characteristics of mixed composition gallstones?

A
  1. Multiple stones
  2. Several generations of different sizes often found together
  3. May be hard and faceted (where they’ve developed in contact) or irregular, mulberry-shaped and softer
  4. Colours range from near-white to yellow and green to black
  5. Most radiolucent but 10% are radiopaque
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14
Q

In addition to mixed composition gallstones what are 3 other types?

A
  1. Cholesterole stones
  2. Pigment stones
  3. Calcium carbonate stones (rare)
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15
Q

What are 5 characteristics of cholesterol stones?

A
  1. Large, smooth, egg- or barrel-shaped
  2. Usually solitary (cholesterol solitaire)
  3. Yellowish
  4. Up to 4cm diameter and may fill gallbladder
  5. Radiolucent
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16
Q

What substance makes up pigment stones and where are they most common?

A

calcium bilirubinate - common in Asia

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17
Q

What causes pigment gallstones?

A

exces bilirubin excretion caused by haemolytic disorders e.g. haemolytic anaemias, infections, malaria, leukaemias

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18
Q

What are 4 characteristics of pigments stones?

A
  1. Multiple, jet-black, shiny ‘jack’ stones
  2. 0.5-1cm in diameter
  3. Usually uniform size
  4. Often friable
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19
Q

What causes calcium carbonate stones?

A

excess calcium excretion in bile

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20
Q

What are 2 characteristics of calcium carbonate stones?

A
  1. Gretish faceted stones
  2. Radiopaque
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21
Q

What is the physical structure of mixed gallstones?

A
  • small core of organic material, often containing bacteria
  • main body made up of concentric layers - formed in series of precipitation events
  • several families of gallstones each of different size in same gallbladder
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22
Q

What is the average gallstone age when it is removed?

A

11 years

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23
Q

Why is removal of the terminal ileum or chronic distal ileal disease thought to cause a 3x increase in risk of developing cholesterol-rich stones?

A
  • terminal ileum is the main site for reabsorption of bile salts
  • when it is diseased/ removed, reabsorption declines, leading to bile salt loss via the bowel + decline in the bile salt pool
  • remaining bile salts are then insufficient to maintain the micellar structure of cholesterol in suspension
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24
Q

What are 2 things that can contribute to biliary stasis, which in turn contributes to gallstone formation?

A
  1. Gallbladder obstruction - of spiral valve in cystic duct, reflux of duodenal contents, small stones already formed
  2. Defective contractility - damage to gallbladder wall by inflammation/infection, pregnancy
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25
Q

What is the role of inflamamtion/infection in gallbladder formation?

A

bacteria usually form organic nidus upon which gallstones are built

bacteria enter gallbladder by reflux from duodenum or via the bloodstream - probably normal process but becomes pathological if bacteria not flushed out e.g. when emptying inadequate

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26
Q

What are 4 pieces of evidence within a gallbladder removed for chronic pain of chronic obstruction?

A
  1. Atrophic mucosa
  2. Submucosal and subserosal fibrosis
  3. Hypertrophy of the muscular wall
  4. Mucosal diverticula extending into the muscular layer (Rokitansky-Aschoff sinuses)
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27
Q

What can be the effect of the changes in gallbladder morphology resulting from chronic obstruction?

A

sometimes so grossly scarred, distorted or contracted that its absorptive and contractile functions have been completely destroyed

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28
Q

What proportion of patients with typical symptoms of gallbladder disease have no stone during investigation/ at operation?

A

10%

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29
Q

What are 3 possible causes of the 10% of patients with symptoms of gallbladder disease who have no stone found?

A
  1. Stone may have passed out of the duct system into the bowel
  2. Acute or chronic inflammation can occur independently of stones - acalculous cholecystitis (may be due to chronic obstruction)
  3. Biliary dyskinesia and cystic duct syndrome can sometimes explain condition where patients have typical symptoms of gallbaldder disease but investigations normal. May be abnormally high presssure in sphincter of Oddi
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30
Q

What proportion of adults develop gallstones during their lifetime in developed countries?

A

at least 10%; most remain asymptomatic

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31
Q

What are 4 risk factors for gallstones?

A
  1. Advancing age (forty)
  2. Female (F:M 4:1)
  3. Obesity/diabetes (fat)
  4. Pregnancy (fetus)
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32
Q

What are 3 objectives of investigation of gall bladder pathology when gallstone disease is suspected?

A
  1. Exclude haematological and liver abnormalities and other metabolic disorders
  2. Establish if gallstones are present in the gallbladder and/or common duct and whether the gallbladder wall is thickened
  3. Assess integrity and patency of bile duct system and pancreatic duct (if suggestion of obstruction)
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33
Q

What are 6 important investigations to consider in gallbladder pathology?

A
  1. Haemoglobinopathy screen (blood test): for haemolytic disorders (hereditary spherocytosis, thalassaemia, sickle-cell trait)
  2. LFTs
  3. Ultrasonography: to look at gallbladder
  4. Non-jaundiced: cholangiography (intraoperative or perioperative) to look at ducts
  5. Endoscopic retrograde cholangiopancreatography (ERCP): if cholangiography shows stones
  6. Jaundiced: magnetic resonance cholangiopancreatography (MRCP)
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34
Q

What is the value of ultrasonography in investigating gall bladder pathology? 3 things it can identify

A
  1. can reliably identify stones in the gall bladder
  2. and any increase in thickness of the wall (caused by inflammation or fibrosis)
  3. can demonstrate dilatation of common duct system, often indicating distal duct obstruction
  • unreliable for identifying bile duct stones
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35
Q

What is ultrasound not good at showing in gall bladder disease?

A

unreliable for directly identifying bile duct stones, particularly at lower end - image tends to be obscured by overlying duodenal gas

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36
Q

What is the key advantage of using ultrasound scans in suspected gall bladder disease?

A

suitable for use in seriously ill or jaundiced patient as non-invasive, can be done at bedside

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37
Q

What can be seen in this ultrasound?

A

longitudinal scan of gallbladder; outline and layer of gallstones can be seen (arrows) along posterior walls. stones cast a clear acoustic shadow (AS) beyond them

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38
Q

What key factor dictates how the biliary duct system is investigated?

A

jaundiced vs non-jaundiced patient

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39
Q

How do investigations differ for jaundiced vs non-jaundiced patients for investigation of the biliary duct system?

A
  • non-jaundiced: no preoperative investigation for duct stones required apart from USS and LFTs. if cholecystectomy needed, intraoperative (or perioperative) cholangiography may be carried out. can do ERCP based on this
  • jaundiced: USS initially then need to differentiate btw stones, strictures, tumour - MRCP done
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40
Q

What does cholangiography for non-jaundiced patients involve?

A
  • cannula passed through cystic duct into the common bile duct and radiopaque contrast material injected to fill biliary tree
  • x-rays or fluoroscopic imaging then used to demonstrate duct morphology and abnormalities, such as duct dilatation, filling defects caused by stone, or distortion of tapering lower end of common duct
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41
Q

If cholangiography in a patient without jaundice shows stones, what may be done next?

A

the duct may be explored at the time, or else dealt with later by endoscopic retrograde cholangiopancreatography (ERCP)

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42
Q

If patients have transient jaundice and suspected gallbladder disease how will they be investigated?

A

will have either operative cholangiography at cholecystectomy, or preoperative ERCP

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43
Q

What is the initial investigation when obstructive jaundice has been diagnosed and what is its purpose?

A
  • ultrasonography: initially helps to answer question of whether obstruction caused by stone, benign stricture or tumour
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44
Q

What are 3 things that may be seen on ultrasound in a person with obstructive jaundice?

A
  1. shows extent of dilatation of intrahepatic and extrahepatic ducts, may even show stone lodged at lower end of the duct
  2. if stones in gall bladder, this suggests stones blocking duct rather than tumour - but the two can coexist
  3. can also demonstrate if carcinoma of pancreatic head or enlarged lymph nodes in porta hepatis present - either may cause extrahepatic biliary obstruction
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45
Q

If an obstructed jaundice pattern of gallbladder disease, what investigation may be performed following ultrasound and why?

A
  • MRCP: USS may make diagnosis but if more info required, biliary tract morphology can be outlined with MRCP - produces images of biliary tree and pancreatic ducts
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46
Q

What can be done in obstructive jaundice if MRCP doesn’t yield the necessary information? 2 methods

A
  1. ERCP
  2. Percutaneous transhepatic cholangiography (rare)
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47
Q

What is an added benefit of ERCP over MRCP in obstructive jaundice?

A

also allows ampullary region to be inspected for tumour

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48
Q

If stones are found in the common bile duct on ERCP, what procedure is it often possible to immediately perform?

A

endoscopic sphincterotomy (aka papillotomy) to release the stones - diagnosis and management of jaundice in 1 procedure

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49
Q

What are 2 examples of uses of endoscopic sphincterotomy during ERCP in obstructive jaundice?

A
  1. life-saving in ascending cholangitis
  2. treatment of choice for patient who is poor risk for laparotomy or laparoscopy
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50
Q

When is percutaneous transhepatic cholangiography used?

A

used in exceptional circumstances e.g. ERCP unsuccessful because of previous gastric surgery

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51
Q

What does percutaneous transhepatic cholangiography involve?

A
  • inserting a long, fine (22-gauge) needle through the skin into one of the dilated intrahepatic ducts under radiological control
  • contrast medium injected
  • obstructing stone produces characteristic rounded filling defect, contrasting with the tapering stricture typical of tumour
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52
Q

What interventions can be performed during percutaneous transhepatic cholangiography? 3 things

A
  1. Stricture dilatation
  2. Stent insertion
  3. combined with ERCP in rendezvous procedure
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53
Q

What is an additional technique sometimes used for imaging in obstructive jaundice?

A

endoscopic ultrasound scanning

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54
Q

What are three advantages of endoscopic ultrasound scanning in obstructive jaundice?

A
  1. shows greater detail at lower end of common bile duct
  2. examines lesions in ampulla or head of pancreas with greater clarity
  3. can perform fine-needle aspiration for histological diagnosis
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55
Q

What are 9 types of clinical consequences of gallstone disease?

A
  1. chronic cholecystitis
  2. biliary colic
  3. acute cholecystitis
  4. mucocele
  5. empyema of the gall bladder
  6. free perforation of gall bladder
  7. fistula formation from CBD to duodenum
  8. gallstone ileus
  9. carcinoma of gall bladder
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56
Q

How can gallstones cause chronic cholecystitis?

A

when they cause chronic, low-grade symptoms

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57
Q

What may be 5 clinical features of chronic cholecystitis due to gallstones?

A
  1. History of intermittent pain in RUQ or epigastrium
  2. Often accompanied by nausea or vomiting
  3. Pain may be brought on by large or fatty meals
  4. Pain may radiate around towards back
  5. Symptoms vague and ill-defined so delay consulting doctor
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58
Q

What may be present on examination in chronic cholecystitis due to gallstones?

A

vague upper abdominal tenderness

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59
Q

What are 5 differentials for chronic cholecystitis?

A
  1. Peptic ulcer disease
  2. UTI
  3. Chronic constipation
  4. Irritable bowel syndrome
  5. Chronic aerophagia (air swallowing)
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60
Q

What is important to remember about vague upper abdominal symptoms and demonstrable gallstones when making the diagnosis?

A

doesn’t prove pain is caused by the stones - if symptoms less specific, more extensive diagnostic search is needed

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61
Q

When symptoms that may suggest chronic cholecystitis are less specific, what investigations may be needed to rule out other causes? 4 things

A
  1. upper GI endoscopy
  2. plasma amylase
  3. ECG
  4. bowel investigations
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62
Q

What is biliary colic?

A

transient obstruction of the gall bladder by stone causing episodes of acute, severe pain

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63
Q

What is the nature of pain from biliary colic?

A
  • severe, typically rises to a plateau over a few minutes then continues unrelentingly
  • doesn’t have strikingly intermittent brief peaks of other forms of colic (e.g. ureteric)
  • pt may be in agony until pain resolves spontaneously after several hours, or after opiate analgesia
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64
Q

What features are commonly associated with biliary colic? 3 things

A
  1. vomiting
  2. exhaustion and soreness for next day or so
  3. history of previous similar episodes
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65
Q

What 2 things may be present on examination in biliary colic?

A
  1. Afebrile
  2. Some local tenderness may be present due to gall bladder distension
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66
Q

What diagnosis is more likely if an attack of biliary colic doesn’t settle within 24 hours?

A

acute cholecystitis

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67
Q

How long do episodes of biliary colic usually last?

A

a few hours

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68
Q

What is the management of most cases of biliary colic?

A
  • most can be safely managed at home if the diagnosis is recognised
  • relief of pain: usually requires only 1 injection of an opiate and the attack passes
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69
Q

What does the management of severe attacks of biliary colic usually involve?

A
  • usually prompt emergency hospital admission since differential includes other conditions that may require urgent operation e.g. perforated peptic ulcer
  • USS should be performed - early diagnosis may save extra days in hospital
  • cholecystectomy scheduled for next available list in acute gallstone disease
    • preferred by many surgeons, others perform electively at later date
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70
Q

What is the current thought about management of acute gallstone disease in terms of cholecystectomy timing?

A

early operation seems to be better option as reduces risk of complications of gallstones

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71
Q

What does the presence of a mucocele of the gall bladder on ultrasound in biliary colic indicate? 2 things

A
  1. Attack likely to persist
  2. High risk of developing empyema of gall bladder
72
Q

What is the management of biliary colic if mucocele is found on USS?

A

cholecystectomy often becomes obligatory during current admission

73
Q

What is mucocele and what causes it?

A

gall bladder distended with mucus: if obstruction doesn’t resolve by itself and the contents of the gallbladder don’t become infected

74
Q

How does a mucocele often appear clinically?

A

often palpable and tender

75
Q

What is the definitive management for attacks of biliary colic?

A

cholecystectomy

76
Q

What are 2 steps of definitive management of attacks of biliary colic?

A
  1. patients put on low-fat diet initially or whilst awaiting operation - to relieve symptoms
  2. cholecystectomy
77
Q

What is usually found following cholecystectomy for biliary colic?

A

gall bladder found to contain stones or thick dark biliary sludge and wall is often thin, may sometimes be inflamed

78
Q

What can cause a gall bladder to be technically more difficult to remove in cholecystectomy?

A

if it is thickened and scarred

79
Q

What is acute cholecystitis?

A

if obstruction of the gall bladder persists, gall bladder becomes chemically inflamed causing this

80
Q

What are 3 things that contribute to acute cholecystitis?

A
  1. Physical irritation
  2. Chemical irritation
  3. Bacterial infection
81
Q

How does acute cholecystitis often present?

A

as a surgical emergency

82
Q

How does the presentation of acute cholecystitis differ from that of biliary colic?

A

fever and tachycardia in acute cholecystitis, afebrile in biliary colic

83
Q

What are 4 signs on examination of acute cholecystitis?

A
  1. Tenderness in RUQ
  2. Tenderness more marked on inspiration
  3. Tender inflammatory gall bladder mass may be palpable
  4. Murphy sign may be present - tenderness at tip of ninth rib
84
Q

How does the clinical course of acute cholecystitis compare to that of biliary colic?

A

acute cholecystitis usually lasts several days before settle or else precipitating urgent surgery; whereas biliary colic usually settles in a few hours

85
Q

What investigation should be performed in acute cholecystitis and what will it show?

A

USS: reveals stones and thickened gall bladder wall

86
Q

What are 3 aspects of the management of acute cholecystitis?

A
  1. Oral intake restricted to fluids, IV infusion set up if necessary
  2. Antbiotics only if accompanied by gall bladder infection
  3. Cholecystectomy
87
Q

What clinically suggests gall bladder infection alongside acute cholecystitis meaning antibiotics should be given?

A

symptoms and signs more marked if concurrent infection

88
Q

What is now the more popular point at which to perform acute cholecystectomy for acute cholecystitis?

A

within a few days of onset of the attack

89
Q

What are 5 advantages of early cholecystectomy for acute cholecystitis?

A
  1. Procedure is as safe as elective surgery
  2. Convenient for the patient
  3. Efficient usage of hospital beds
  4. Avoids the delay during which there’s a risk of acute attacks or another manifestation e.g. pancreatitis
  5. Even if delayed cholecystectomy preferred, acute attack may not settle necessitating cholecystectomy on same admission anyway
90
Q

What are 5 findings when cholecystectomy is performed during acute cholecystitis?

A
  1. Gall bladder is obstructed and tense and may be grossly inflamed, thickened and scarred
  2. Serosal surface is oedematous and inflamed with petechial haemorrhages of purulent exudate
  3. Fibrinous adhesions to nearby structures
  4. Gall bladder neck or cystic duct blocked by impacted stone
  5. Gall bladder usually contains further stones or sludge mixed with inflammatory exudate
91
Q

What must care be taken towards during acute cholecystectomy for acute cholecystitis?

A

to avoid damaging the bile ducts

92
Q

In what proportion of cases of acute cholecystitis can bowel organisms be cultured from the contents of the gall bladder?

A

70%

93
Q

What must be done during the cholecystectomy procedure for acute cholecystitis and why?

A

A bacterial culture swab should be taken from within the gall bladder at operation as any postoperative infective complications are likely to involve the same organisms

94
Q

What is present clinically with an empyema of the gall bladder?

A
  1. swinging pyrexia often found
  2. signs of generalised peritonitis if perforation
95
Q

What can empyema of the gall bladder result in?

A
  • sometimes part of gall bladder wall becomes necrotic, leading to perforation and causing subphrenic abscess or generalised peritonitis
96
Q

Why are gangrenous cholecystitis and perforation rare?

A

gall bladder has a rich blood supply from its hepatic bed, as well as fom the cystic artery

97
Q

What causes cholecystoduodenal fistulae and gallstone ileus? What does it lead to?

A
  • when the inflamed gall bladder becomes adherent to the adjacent duodenum and a stone ulcerates through the wall to form a cholecystoduodenal fistula
  • fistula decompresses the obstructed gall bladder and allows stones to pass into the bowel and gas to enter the biliary tree
98
Q

How can cholecystoduodenal fistulae be diagnosed?

A
  • usually painless and unsuspected
  • can be diagnosed on plain abdominal x-ray by presence of gas outlining biliary tree
  • sometimes discovered at operation
99
Q

When can cholecystoduodenal fistulae lead to gallstone ileus?

A

if solitary cholesterol stone passing into bowel is so large that after traversing small bowel it impacts in the narrowest part, the distal ileum, causing small bowel obstruction or gallstone ileus

100
Q

In which patient group does gallstone ileus tend to occur?

A

elderly

101
Q

How does gallstone ileus typically present?

A

unexplained intermittent and sometimes incomplete small bowel obstruction

102
Q

Why is a diagnosis of gallstone ileus usually difficult to make?

A

as stone is usually radiolucent

103
Q

How is a diagnosis of gallstone ileus made?

A
  • in elderly patient with distal small bowel obstruction, need to consider this diagnosis
  • plain abdo x-ray: can confidently make diagnosis if gas recognised in biliary tree
104
Q

What can cause carcinoma of the gall bladder? Which type of carcinoma is this?

A

chronic irritation by stone over a long period of time - believed to predispose to adenocarcinoma of GB

105
Q

What may be the presentation of carcinoma of the gall bladder? 3 things

A
  1. similar to chronic inflammatory gall bladder disease
  2. jaundice may develop if tumour obstructs bile ducts
  3. usually unexpected finding at cholecystectomy for stones (often incurable at time of detection)
106
Q

Where do bile duct stones nearly always originate from?

A

gall bladder - pass through cystic duct

107
Q

What happens to most bile duct stones?

A

most are small enough to pass out of biliary system into the duodenum, but may cause biliary colic or mild jaundice during transit

108
Q

Where do bile duct stones tend to lodge?

A

narrowest point in common bile duct - at the lower end

109
Q

What is the clinical presentation of stones in the biliary tract?

A
  • obstructive jaundice
  • progressive jaundice or intermittent jaundice
110
Q

What happens to the biliary tree long term with bile duct gall stones?

A
  • results in gradual dilatation of biliary tree; longstanding dilatation does not regress even after obstruction removed, may lead to stagnation of bile and further stone formation
111
Q

What is Courvoisier law?

A

gall bladder rarely distends with bile duct stones even when CBD completely obstructed, due to inflammatory fibrosis or mural hypertrophy caused by gallstones

112
Q

What can cause gall stones in the biliary tree to cause acute pancreatitis?

A
  • stones passing through or lying near the ampulla of Vater may interfere with drainage of pancreatic enzymes into the duodenum
  • bile reflux into the main pancreatic duct may then cause acute pancreatitis
113
Q

How may asymptomatic bile duct stones be detected?

A

any patient with gallstones usually have operative cholangiography (but asymptomatic duct stones are rare)

114
Q

Other than being asymptomatic, how else may a cholecystoduodenal fistula present?

A

gallstone ileus can present as distal small bowel obstruction (as stone travels to distal ileum and impacts there)

115
Q

How can bile duct stones cause progressive jaundice?

A

if a stone becomes impacted in the common bile duct at its lower end (where it is narrowest) and the stone is too large to pass out

116
Q

How can bile duct stones cause intermittent jaundice?

A

the stone can act as a ball-valve at the lower end of the CBD

117
Q

What are 4 clinical presentations of stones in the biliary tract?

A
  1. Obstructive jaundice
  2. Asymptomatic duct stones
  3. Acute pancreatitis
  4. Ascending cholangitis
118
Q

How can gallstones in the biliary tree lead to ascending cholangitis?

A

bile stasis in the common duct occurs with chronic obstruction and dilatation and predisposes to bacterial infection

119
Q

What are 4 things that characterise ascending cholangitis, caused by gallstones in the biliary tree?

A
  1. Intermittent attacks of pain
  2. Swinging pyrexia
  3. Jaundice
  4. Potent cause of systemic sepsis
120
Q

What approach does the majority of treatment for gallstone disease involve?

A

most cases treated surgically

121
Q

What alternative treatment of gallstone disease may be considered for patients not fit for surgery?

A

oral drug therapy - chenodeoxycholic acid (bile acid) and related drugs

122
Q

How do chenodeoxycholic acid/relate ddrugs work to treat gallstone disease?

A
  • increase the bile salt pool and inhibit hepatic cholesterol secretion
  • when administered over a long period, cause slow dissolution of cholesterol stones
123
Q

What are 4 disadvantages of the use of chenodeoxycholic acid/related drugs to treat gallstone disease?

A
  1. Very slow action
  2. Only small (<1cm) cholesterol-predominant stones can be dissolved
  3. High rate of stone recurrence after successful treatment - up to 50% after 2 years
  4. Frequent drug-related side effects e.g. severe diarrhoea and hepatic damage
124
Q

What are 2 examples of drug-related side effects of chenodeoxycholic acid / similar bile acids?

A
  1. Severe diarrhoea
  2. Hepatic damage
125
Q

What are 3 criteria that must be met for drug therapy to be used as treatment for gallstone disease (ursodeoxycholic acid etc.)?

A
  1. Patients unfit for general anaesthesia
  2. Small radiolucent stones in gall bladder
  3. Gall bladder concentrates contrast and contracts in response to a fatty meal
126
Q

What are the 2 main indications for cholecystectomy?

A
  1. Symptomatic gallstone disease
  2. Asymptomatic gallstones, when there is a reasonable likelihood of future symptoms or complications
127
Q

What is usually the only imaging study required prior to cholecystectomy for gallstone disease?

A

usually high-quality biliary ultrasound is only imaging study required

128
Q

Is info from ultrasound about gall bladder wall thickness or number and size of stones useful in predicting feasibility of laparoscopic surgery?

A

no

129
Q

If there are stones in the bile duct system, what are 2 approaches to manage this?

A
  1. Common duct exploration added to cholecystectomy
  2. Stones extracted at ERCP
130
Q

What are 5 things that any jaundiced patient is at particular risk of during surgery?

A
  1. Infection
  2. Hepatic impairment
  3. Defective clotting
  4. Acute renal failure
  5. Venous thrombosis
131
Q

What is done in many patients who are jaundiced prior to surgical intervention for gallstones?

A

preferable to relieve obstructive jaundice before surgery, by endoscopic sphincterotomy and stone extraction or bile duct stenting, to minimise complications

132
Q

In what cause of obstructive jaundice is it preferable to proceed to surgery without biliary stenting and why?

A

operable carcinoma of panreas: to avoid complications of the procedure, namely cholangitis and pancreatitis

133
Q

What pre-op intervention to remove an operable pancreatic carcinoma is sometimes performed and why?

A

some require pre-operative drainage to alleviate symptoms related to jaundice and improve fitness for major surgery

134
Q

What is the gold standard treatment for gallstones?

A

laparoscopic cholecystectomy

135
Q

What must all surgeons who perform a lap chole be able to do?

A

must be able to perform open cholecystectomy - due to occasional conversion to open operation due to unexpected difficulties/complications

136
Q

What are 2 examples of absolute contraindications to laparoscopic cholecystectomy?

A
  1. Late stages of pregnancy
  2. Uncorrected major bleeding disorders
137
Q

What are 5 relative contraindications for laparoscopic management of gall bladder disease (for less experienced surgical teams)?

A
  1. Morbid obesity
  2. Acute cholecystitis
  3. Untreated bile duct stones including obstructive jaundice
  4. Previous abdominal surgery (adhesions)
  5. Intraabdominal malignancy
138
Q

What proportion of patients require conversion from laparoscopic cholecystectomy to open surgery?

A

1-5%

139
Q

If bile duct stones are suspected what investigation prior to cholecystectomy is advisable?

A

pre-operative ERCP (or equivalent MR investigation), and stone extraction may be carried out

140
Q

What proportion of biliary stones can be successfully extracted by endotherapy?

A

95% +

141
Q

Some surgeons only perform operative cholangiography in select patients; which 3 patient groups may be selected for this?

A
  1. Patients who have had abnormal LFTs at any time
  2. Patients who have a dilated duct on ultrasound scanning
  3. Patients with clinical evidence of earlier passage of stone (e.g. previous acute pancreatitis or jaundice)
142
Q

What are the 7 main steps of performing a cholecystectomy?

A
  1. cystic artery is isolated, clipped or ligated and divided
  2. the junction between the cystic duct and common bile duct clearly identified - so bile duct not at risk
  3. cystic duct clipped or ligated near gall bladder
  4. small incision made in cystic duct, cannula inserted and secured with ligature
  5. contrast medium injected in two or three stages and x-ray fluorscopy used to demonstrate biliary tree and flow through ampulla i.e. operative cholangiography
  6. cystic duct divided and stump ligated with absorbable tie or clipped
  7. gall bladder dissected out of liver bed, commencing either at neck or fundus
143
Q

How is a cholangiogram performed during the cholecystectomy procedure?

A

percutaneously, across the abdominal wall

144
Q

After a laparoscopic cholecystectomy, within what time frame are most patients able to walk and tolerate food?

A

within 6 hours of operation

145
Q

Within what time frame can most (80%) of patients be discharged following a laparoscopic cholecystectomy?

A

within 24 hours

146
Q

What risk of surgery increased with laparoscopic cholecystectomy vs open surgery?

A

higher risk of bile duct injuries

147
Q

What are 3 things illustrating how the consequences of bile duct injury can be catastrophic?

A
  1. Can die from multiorgan failure resulting from unrecognised biliary peritonitis
  2. May require open operations to repair bile ducts
  3. Risk of consequences of long-term bile duct strictures
148
Q

How can the common bile duct be explored if stones are known to be present in the bile ducts?

A
  • may be explored laparoscopically or at open surgery
  • open through incision and stones retrieved by combo of manipulation/irrigation/gasping with forceps or Dormia basked, or use of balloon catheter
  • operative choledochoscopy used to check for residual stones/ remove difficult ones
  • T tube inserted afterwards
149
Q

What is T tube cholangiography?

A

latex T tube placed to drain bile from common bile duct

reduces risk of iatrogenic biliary stricture and bile leak, and 1 week later, provides access to biliary tree for further cholangiogram after operation - T-tube cholangiography

150
Q

What is the purpose of T-tube cholangiography?

A

to ensure that no stones remain and to allow any oedema at the ampulla to settle

151
Q

Which techniques mean that bile duct stones can often be retrieved without an operation?

A

ERCP and endoscopic sphincterotomy

152
Q

What are 5 situations when endoscopic sphincterotomy can be performed?

A
  1. Urgent drainage of the bile duct in obstructive jaundice complicated by cholangitis. Definitive surgery can be deferred until risks of infection minimised
  2. Retrieval of stones missed at operation
  3. Removal of duct stones in patients unfit for operation
  4. Some cases of acute pancreatitis caused by gallstones
  5. Preparation of a jaundiced patient for elective gall bladder surgery
153
Q

What are 7 complications of biliary surgery?

A
  1. Retained stone
  2. Biliary peritonitis
  3. Bile duct damage
  4. Haemorrhage
  5. Hazards of pre-existing jaundice
  6. Ascending cholangitis and other infections
  7. Subphrenic abscess
154
Q

How can retained stones following complications of biliary surgery be revealed?

A

post-operative T-tube cholangiography

155
Q

How are retained stones following biliary surgery usually retrieved?

A

ERCP and sphincterotomy - also possible percutaneously via mature T-tube track using steerable grasping forceps or Dormia basket

156
Q

How can biliary peritonitis occur due to biliary surgery?

A

bile leaking into the peritoneal cavity - it is an irritant so causes chemical peritonitis

157
Q

How can biliary peritonitis lead to sepsis?

A

if the bile is infected, it causes genearlised peritonitis and sepsis

158
Q

Why does bile have a tendency to leak through suture lines, and what should be done due to this risk?

A
  • due to its detergent action
  • drain should be left in vicinity for at least 5 days
159
Q

What is usually the outcome of small bile leaks after biliary operations?

A

usually settle spontaneously

160
Q

What is the management of biliary peritonitis (due to a bile leak) after biliary surgery?

A

area must be urgently drained percutaneously or, more often, reexplored surgically and drained, with IV antibiotic cover

161
Q

What is the most serious type of bile duct damage?

A

unrecognised transection or ligation of the common duct

162
Q

How can damage to the common duct present?

A

major biliary leak or increasing jaundice

163
Q

If serious common bile duct damage is suspected, what is the management?

A

urgent reexploration and reconstruction

164
Q

If lesser degrees of bile duct damage e.g. from crushing, overuse of diathermy or careless ligature occurs, what is the likely outcome?

A

they will heal but eventually cause fibrotic stricture, which presents much later with obstruction

165
Q

What things are needed for reconstructive surgery if bile ducts are damaged?

A

usually needs to be done at a tertiary centre and early referral critical

166
Q

What are 6 potential complications of lap chole surgery due to placement of the insufflation needle, trocar or other instruments?

A
  1. Injuries to bowel
  2. Injuries to blood vessels, e.g. iliac artery
  3. Diaphragmatic injury with tension pneumothorax
  4. Bleeding from trocar insertion sites
  5. Subcutaneous emphysema
  6. Herniation through trocar entry points and bowel strangulation
167
Q

What are 7 examples of trauma to the biliary system due to laparoscopic cholecystectomy?

A
  1. Injuries to common bile ducts and hepatic ducts
  2. Bleeding from cystic or right hepatic artery
  3. Gall bladder perforation with spillage of bile and stones
  4. Bleeding and bile leakage from liver bed
  5. Bile leakage and cystic duct remnant
  6. Retained bile duct stones
  7. Bowel damage by diathermy or laser
168
Q

What are 3 places where haemorrhage is likely to occur from due to biliary surgery?

A
  1. Cystic artery
  2. Hepatic artery
  3. Vascular liver bed
169
Q

What factor can make haemorrhage from biliary surgery more likely?

A

removing a grossly inflamed or fibrotic gall bladder

170
Q

What can occur secondary to maenouevres to control haemorrhage?

A

may damage other structures, passing unnoticed at the time - common cause of bile duct trauma

171
Q

What can cause ascending cholangitis due to biliary surgery?

A
  • anastomosis forms between bile ducts and bowel
  • reflux of intestinal contents and organisms takes place continually
  • active infection occurs when bile stagnates in the duct system because of inadequate drainage - usually when diameter of anastomosis has shrunk so can no longer drain adequately
172
Q

What should be done to minimise the risk of ascending cholangitis from biliary surgery?

A

prophylactic antibiotics given

173
Q

When should a subphrenic abscess be suspected?

A

after biliary surgery - usually a few days after operation, develops unexplained swinging fever

174
Q

How is a diagnosis of subphrenic abscess best made?

A

by ultrasound

175
Q

What is the treatment of a subphrenic abscess?

A

by percutaneous needle drainage under US guidance, occasionally by open operation

AIP: Abdominal pain (20 decks)

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