Cholecystitis and cholangitis

Question 1

Acute cholecystitis definition

Answer 1

acute inflammation of the gallbladder

Question 2

Acute cholecystitis risk factors

Answer 2

• gallstones
• severe illness - hypotension, trauma, burns
• TPN
• diabetes

Question 3

Acute cholecystitis pathophysiology

Answer 3

• gallstones obstruct gallbladder neck/cystic duct
• acute inflammation of gallbladder wall
• bile remains trapped
• prostaglandin release due to irritation
• usually no jaundice as bile can pass into cystic ducts

Question 4

Mirizzi syndrome

Answer 4

• gallbladder inflammation leads to increased pressure on contiguous biliary ducts
• leads to jaundice

Question 5

Acute cholecystitis signs and symptoms

Answer 5

• RUQ pain and tenderness
• Murphy’s sign positive
• palpable mass
• signs and symptoms of inflammation

Question 6

Acute cholecystitis diagnosis

Answer 6

• ultrasound - distension, wall thickening, gallstones
• bloods - FBC, CRP, bilirubin, LFTs, serum amylase (to exclude pancreatitis)
• consider cholescintigraphy
• CT/MRI - to identify infection causing sepsis if present

Question 7

Acute cholecystitis management

Answer 7

• analgesia
• fluid resuscitation
• refer for laparoscopic cholecystectomy

Question 8

Ascending cholangitis definition

Answer 8

acute, ascending inflammation of the biliary tree

Question 9

Ascending cholangitis risk factors

Answer 9

• age over 50
• gallstones
• stricture (benign or malignant)
• history of sclerosing cholangitis
• bile duct injury, e.g. from ERCP

Question 10

Ascending cholangitis pathophysiology

Answer 10

• gallstones stuck in the biliary tree cause obstruction
• this leads to bacterial seeding in the gallbladder and sludge formation
• haematogenous spread can lead to sepsis

Question 11

Ascending cholangitis signs and symptoms

Answer 11

• Charcot’s triad - fever, RUQ pain, jaundice
• Reynold’s pentad - also includes shock and altered mental state

Question 12

Ascending cholangitis investigations

Answer 12

• FBC and CRP raised
• abnormal LFTs, almost always with hyperbilirubinaemia
• transabdominal ultrasound to differentiate from cholecystitis

Question 13

Ascending cholangitis management

Answer 13

• broad-spectrum IV antibiotics and IV hydration
• correct electrolytes and coagulation
• ERCP within 24-48 hours to relieve obstruction

Question 14

Biliary colic

Answer 14

• pain from gallbladder or biliary contraction around gallstones
• “fat, female, fertile, forties”
• can progress, eventually needs cholecystectomy