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Surgery > Cholelithiasis > Flashcards

Cholelithiasis Flashcards

1
Q 
Description of : 
Cholelithiasis ?
Choledocholithiasis ?	
Acute cholecystitis ?
Acute cholangitis ?
A

Cholelithiasis : Presence of gallstones in the gallbladder

Choledocholithiasis : Presence of gallstones in the common bile duct

Acute cholecystitis : Acute inflammation of the gallbladder

Acute cholangitis : Bacterial infection of the biliary tract

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2
Q 
Mechanism of : 
Cholelithiasis ?
Choledocholithiasis ?	
Acute cholecystitis ?
Acute cholangitis ?
A

Cholelithiasis : Bile cholesterol oversaturation, bile stasis, impaired bile acid circulation → precipitation of gallstones in the gallbladder

Choledocholithiasis : Cholelithiasis → migration of gallstones into the common bile duct

Acute cholecystitis : Cholelithiasis (most common) or biliary sludge → inflammation of gallbladder wall

Acute cholangitis : Choledocholithiasis (most common) → obstruction and stasis within the biliary tract → subsequent bacterial infection

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3
Q 
Clinical features of 
Cholelithiasis ?
Choledocholithiasis ?	
Acute cholecystitis ?
Acute cholangitis ?
A

Cholelithiasis :
Usually asymptomatic
Symptomatic (biliary colic): RUQ pain < 6h

Choledocholithiasis :
RUQ pain > 6 h
Possible jaundice

Acute cholecystitis :
RUQ pain
Fever
Murphy sign

Acute cholangitis :
Charcot triad: RUQ pain, fever, jaundice
Reynold pentad: Charcot cholangitis triad PLUS hypotension and mental status changes

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4
Q 
Laboratory findings	 of ?
Cholelithiasis ?
Choledocholithiasis ?	
Acute cholecystitis ?
Acute cholangitis ?
A

Cholelithiasis ? Normal

Choledocholithiasis ?	
↑ Total bilirubin
↑ GGT
↑ ALP
↑ AST, ALT

Acute cholecystitis ? ↑ WBC, CRP

Acute cholangitis ?
↑ WBC and CRP
↑ ALP
↑ AST, ALT
↑ Total bilirubin
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5
Q 
Diagnostic imaging of :
Cholelithiasis ?
Choledocholithiasis ?	
Acute cholecystitis ?
Acute cholangitis ?
A

Cholelithiasis ?
US: gallstones with posterior acoustic shadow

Choledocholithiasis ?
US: dilated common bile duct, intrahepatic biliary dilatation
MRCP or ERCP: filling defect in the contrast-enhanced duct

Acute cholecystitis ?
US: gallbladder wall thickening and/or edema (double wall sign)
HIDA scan: nonvisualization of gallbladder > 4 hours after radioactive tracer administration

Acute cholangitis ?
US: biliary dilation, and/or evidence of obstruction (e.g., cholelithiasis), pericholecystic inflammation
MRCP if diagnosis uncertain

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6
Q 
Treatment 
Cholelithiasis ?
Choledocholithiasis ?	
Acute cholecystitis ?
Acute cholangitis ?
A 
Cholelithiasis ?
Supportive care, analgesics
Elective cholecystectomy for:
Symptomatic cholelithiasis
Asymptomatic cholelithiasis only if at increased risk of gallbladder cancer

Choledocholithiasis ?
Supportive care, analgesics
Endoscopic stone retrieval
Elective cholecystectomy to prevent recurrence

Acute cholecystitis ?
Supportive care, analgesics
IV antibiotics
Cholecystectomy (timing depends on severity)

Acute cholangitis ?
Supportive care, analgesics
IV antibiotics
Urgent biliary decompression
Interval cholecystectomy if gallstones are present or concurrent cholecystitis
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7
Q

In cholelithiasis epidemiology:
Sex:
Prevalence:
Peak incidence:

A

Sex: ♀ > ♂ (2–3:1)

Prevalence: approx. 10–20% of the adult population in developed countries

Peak incidence: > 40 years

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8
Q

In cholelithiasis ,
Imbalance in ………., ……………, ………….., ………….., and …………. .

……………… is a key component in gallstone formation.

Impaired ………….. (e.g., due to bowel rest, prolonged total parenteral nutrition, pregnancy ) → …………. → ……………

A

Imbalance in bile salts, lecithin (stabilizer), cholesterol, calcium carbonate, and bilirubin

Biliary stasis is a key component in gallstone formation.

Impaired gallbladder emptying (e.g., due to bowel rest, prolonged total parenteral nutrition, pregnancy ) → biliary sludge → bile stasis (cholestasis)

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9
Q

cholelithiasis increased in pregnancy?

A

During pregnancy, increased progesterone levels cause smooth muscle relaxation, decreased and impaired gallbladder contraction, and subsequent bile stasis and formation of gallstones.

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10
Q

In cholelithiasis , Cholesterol stones risk factor ? 9

A
  1. Obesity, insulin resistance, dyslipidemia
  2. Female sex
    Especially during reproductive years due to increased levels of estrogen and progesterone
    Increased estrogen levels cause increased secretion of bile rich in cholesterol, (lithogenic bile), which can result in the formation of cholesterol gallstones.
    Increased progesterone levels cause smooth muscle relaxation, decreased gallbladder contraction, and subsequent bile stasis with formation of gallstones.
  3. Multiparity or pregnancy, Estrogen levels dramatically increase during pregnancy, which, in turn, increases the likelihood for cholesterol gallstone formation.
  4. Age (> 40 years of age)
  5. European, Native American, or Hispanic ancestry
  6. Family history
  7. Drugs: fibrates (inhibition of cholesterol 7-α hydroxylase), estrogen therapy, oral contraceptives
  8. Malabsorption (e.g., Crohn disease, ileal resection, cystic fibrosis), Bile acids emulgate cholesterol.
  9. Rapid weight loss
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11
Q

In cholelithiasis, Cholesterol stones (up to ………… of all stones)?

A

95%

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12
Q

In cholelithiasis, Cholesterol stones pathophysiology?

A

abnormal hepatic cholesterol metabolism → ↑ cholesterol concentration in bile and ↓ bile salts and lecithin → hypersaturated bile → precipitation of cholesterol and calcium carbonate → cholesterol stones or mixed stones

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13
Q

In cholelithiasis , During pregnancy, increased estrogen levels cause ……………….. .
Increased progesterone levels cause ……………… .

A

During pregnancy, increased estrogen levels cause increased secretion of lithogenic bile (rich in cholesterol), resulting in the formation of cholesterol gallstones.

Increased progesterone levels cause smooth muscle relaxation, decreased and impaired gallbladder contraction, and subsequent bile stasis and formation of gallstones.

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14
Q

In cholelithiasis, Cholesterol stones Rule of the 6 Fs ?

A

Rule of the 6 Fs: Fat, Female, Fertile, Forty, Fair-skinned, Family history.

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15
Q

In cholelithiasis , Black pigment stones (

A

10%

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16
Q

In cholelithiasis , Black pigment stones risk factor?

A
  1. Chronic hemolytic anemias (e.g., sickle cell disease, hereditary spherocytosis)
  2. (Alcoholic) cirrhosis
  3. Crohn disease
  4. Total parenteral nutrition
  5. Advanced age
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17
Q

In cholelithiasis , Black pigment stones Pathophysiology?

A

↑ hemolysis → increase in circulating unconjugated bilirubin → increased uptake and conjugation of bilirubin → precipitation of bilirubin polymers and stone formation

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18
Q

In cholelithiasis, Mixed/brown pigment stones (

A

10%

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19
Q

In cholelithiasis, Mixed/brown pigment stones risk factor ?

A

Risk factors:
1. bacterial infections and parasites (e.g., Clonorchis sinensis, Opisthorchis species) in the biliary tract

  1. sclerosing cholangitis
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20
Q

In cholelithiasis, Mixed/brown pigment stones pathophysiology?

A

infection or infestation → release of β-glucuronidase (by injured hepatocytes and bacteria) → hydrolyzes conjugated bilirubin and lecithin in the bile → increased unconjugated bilirubin and fatty acids → precipitation of calcium carbonate, cholesterol, and calcium bilirubinate (dark color) in bile

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21
Q

Type of stone In cholelithiasis ?

A
  1. Cholesterol stones (up to 95% of all stones)
  2. Black pigment stones (< 10% of all stones)
  3. Mixed/brown pigment stones (< 10% of all stones)
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22
Q

cholelithiasis clinical symptoms?

A
  1. Most gallstones are asymptomatic.
  2. Biliary colic: constant, dull RUQ pain lasting < 6 hours
    Especially postprandial
    May radiate to the epigastrium, right shoulder, and back (referred pain)
  3. Nausea, vomiting, early satiety
  4. Bloating, dyspepsia
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23
Q

In cholelithiasis,
Why postprandial pain ?
Why referred pain ?

A

Especially postprandial: vagal stimulation (e.g., cholecystokinin release following a fatty meal) → gallbladder contraction → attempts to force the stone into the cystic duct

Biliary pain due to increased intraluminal pressure also causes referred pain secondary to diaphragmatic irritation via the phrenic nerve, which innervates both the diaphragm and the shoulder.

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24
Q

Only a minority of patients with gallstones are …………. !

A

symptomatic

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25
Q

Approach to cholelithiasis ?

A

Asymptomatic cholelithiasis: No diagnostic workup is required.

Suspected symptomatic cholelithiasis

  1. Imaging is essential to confirm a clinical diagnosis of cholelithiasis and rule out concurrent choledocholithiasis.( Choledocholithiasis should be ruled out in all patients with symptomatic cholelithiasis. A normal CBD diameter on RUQ ultrasound reliably rules out choledocholithiasis.)
    • ** RUQ ultrasound is the preferred initial diagnostic test.
    • ** MRCP may be considered if ultrasound findings are inconclusive.
  2. If choledocholithiasis is suspected : See ‘‘Diagnosis of choledocholithiasis.”
  3. If the clinical diagnosis is unclear: See “Diagnosis of acute abdominal pain.”
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26
Q

Diagnosis of cholelithiasis use ?

A
  1. Laboratory
  2. Imaging
    US
    Xray
    CT scan
    MRCP
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27
Q

In cholelithiasis Laboratory studies ?

A

Laboratory studies are typically normal in uncomplicated cholelithiasis but should be ordered to rule out other acute biliary conditions and/or other causes of acute abdominal pain.

CBC , LFT , Amylase and lipase

CBC: usually normal, Important for differentiating biliary colic from the early stages of acute cholecystitis and cholangitis

LFTs: usually normal, Conjugated hyperbilirubinemia, ↑ GGT, and ↑ ALP should increase suspicion for choledocholithiasis.

Amylase, lipase: usually normal, Acute pancreatitis is a complication of cholelithiasis as well as an important differential diagnosis of acute upper abdominal pain. Therefore, amylase and lipase should be ordered in all patients with acute RUQ pain.

28
Q

In cholelithiasis , RUQ ultrasound Indication and Characteristic findings ?

A

Indication: best initial test in suspected symptomatic cholelithiasis

Characteristic findings

  1. Cholelithiasis
    * Intraluminal highly echogenic foci
    * Strong posterior acoustic shadowing
  2. Biliary sludge
    * Low-level echogenic material in the dependent portion of the GB
    * No posterior acoustic shadowing
    * Slow movement with the changing of patient posture
29
Q

Biliary sludge may manifest with ………. and is a risk factor for ……… .

Biliary sludge should be considered in patients with …………… .

A

Biliary sludge may manifest with *biliary colic * and is a risk factor for cholangitis and biliary pancreatitis .

Biliary sludge should be considered in patients with * classic symptoms of biliary colic if cholelithiasis cannot be visualized on ultrasound* .

30
Q

In cholelithiasis , MRI abdomen without and with IV contrast with MRCP Indications and Supportive findings ?

A

Indications

  1. Preferred second-line test if ultrasound findings are inconclusive
  2. Suspected choledocholithiasis , eg., obstructive jaundice on laboratory studies or dilated CBD on ultrasound. ERCP is preferred over MRCP in patients at high risk of choledocholithiasis
  3. MRI without contrast is preferred in pregnant patients.

Supportive findings: well-defined hypointense (on T2) filling defect(s) within the gallbladder lumen

31
Q

In cholelithiasis, CT abdomen with IV contrast Indications , Supportive findings and Disadvantages ?

A

Indications

  1. Inconclusive ultrasound findings; MRI is not available
  2. Suspected complications and/or differential diagnoses, E.g., choledocholithiasis (dilated CBD), acute cholecystitis (GB wall edema, pericholecystic fat stranding), acute pancreatitis (edematous pancreas, mesenteric fat stranding)
  3. Preoperative planning after confirming the diagnosis, E.g., cholelithiasis within the GB infundibulum increases the likelihood of converting laparoscopic surgery to open surgery.

Supportive findings (of radiopaque stones): well-defined hyperdense structure(s) within the gallbladder lumen

Disadvantages
Only radiopaque stones are detectable (15–20% of stones are radiopaque)
Cannot detect the more common radiolucent pure cholesterol stones

32
Q

In cholelithiasis, Abdominal x-ray Indication and Findings and disadvantages ?

A

Indication: usually performed as part of the routine workup of acute abdominal pain

Findings and disadvantages: similar to those of CT scan

33
Q

X-ray and CT scan are rarely diagnostic in cholelithiasis because ……… .

Pure cholesterol stones are ……… .

A

only 15–20% of stones are radiopaque

radiolucent

34
Q

Laboratory studies (e.g., WBC count, bilirubin, amylase) are usually………. in uncomplicated cholelithiasis.

A

normal

35
Q

Ddx of cholelithiasis ?

A

Differential diagnosis of RUQ pain

Differential diagnoses of intraluminal gallbladder wall pathology

36
Q

Differential diagnosis of RUQ pain ?

A 
1. Abdominal
Choledocholithiasis
Acute cholecystitis
Acute cholangitis
Acute hepatic capsule swelling (e.g., acute hepatitis, perihepatitis, congestive hepatopathy)
Gastroesophageal reflux, gastritis, gastrointestinal ulcers
Early appendicitis
Acute pancreatitis
Right-sided diverticulitis 
Sphincter of Oddi dysfunction
  1. Extra-abdominal
    Nephrolithiasis
    Posterior wall infarct
  2. See also “Differential diagnosis of acute abdomen.”
37
Q

Differential diagnoses of intraluminal gallbladder wall pathology ?

A

Cholangiocarcinoma (see biliary cancer)

Gallbladder polyp

38
Q

Gallbladder polyp Definition , Epidemiology and Diagnosis?

A

Definition: benign tumor of the gallbladder wall with low metastatic potential , Gallbladder polyps consist of cholesterol-containing macrophages covered by normal epithelial tissue in > 90% of cases.

Epidemiology
5% of polyps are adenomas, which are premalignant
Up to 50% of polyps > 1 cm are carcinomas

Diagnosis: Ultrasound (transabdominal or endoscopic)

  • Parietal echogenic tumor, easily mistaken for a gallstone
  • No change in position of pathology during movement or acoustic shadow (in contrast to a gallstone)
39
Q

Approach of treatment in cholelithiasis ?

A
  1. All patients
    * Provide supportive care.
    * Identify and treat concurrent choledocholithiasis
  2. Asymptomatic cholelithiasis
    * Expectant management
    * Consider elective cholecystectomy in patients at high risk of developing complications or gallbladder cancer.
  3. Symptomatic uncomplicated cholelithiasis
    * Elective cholecystectomy is the mainstay of treatment.
    * Acute presentation with biliary colic: elective cholecystectomy
    * Surgery not feasible: Consider conservative management with oral bile acid dissolution therapy and/or extracorporeal shockwave lithotripsy.
  4. Symptomatic complicated cholelithiasis: See “Acute cholecystitis”, “Choledocholithiasis”, and “Acute cholangitis.”
40
Q

Treatment of biliary colic

( Initial supportive therapy of acute biliary disease ) ?

A
  1. Bowel rest: NPO
  2. Analgesics
    * NSAIDs: preferred first-line analgesics
    - Ketorolac
    - Diclofenac
    - Ibuprofen
    * Opioids: for severe pain that does not improve with NSAIDs or in patients with contraindications to NSAIDs
    - Morphine
    - Buprenorphine
    - Meperidine
  3. Spasmolytics (e.g., dicyclomine): consider as adjuvant therapy with analgesics in patients with severe pain
  4. In patients with protracted vomiting consider the following:
    IV fluid therapy
    Antiemetics
    Nasogastric tube insertion with suction
41
Q

Why to use NSAIDs not opioids in biliary colic ?

A

NSAIDs are the most effective analgesics for biliary pain and they do not cause sphincter of Oddi spasm. NSAIDs may also prevent disease progression and the development of complications, such as acute cholecystitis.

There is a theoretical risk of sphincter of Oddi spasm with opioid use and this risk is thought to be lower with buprenorphine and meperidine.

42
Q

Important considerations in treatment of biliary colic ?

A

Advise patients to avoid foods with a high fat content, High-fat foods can trigger an acute attack.

Schedule an elective cholecystectomy, If surgery is not feasible or the patient refuses surgery, consider nonsurgical alternatives.

43
Q

Surgical management in treatment of biliary colic Procedure and indication?

A

Procedure: elective laparoscopic cholecystectomy

Indications
1. Symptomatic cholelithiasis
2. Asymptomatic cholelithiasis with any of the following:
@ Increased risk of gallbladder cancer (e.g., gallbladder polyps, porcelain gallbladder, gallstones ≥ 3 cm)
@ Increased risk of developing complications (e.g., immunocompromised patients, multiple gallstones)
@ Increased risk of becoming symptomatic (e.g., hemolytic anemia, patients undergoing gastric bypass surgery)

44
Q

Surgical management in treatment of biliary colic Contraindication and Preoperative precautions and timing ?

A

Contraindication: suspected gallbladder cancer, If gallbladder cancer is suspected preoperatively, an open procedure is currently recommended.

Preoperative precautions: Assess for predictors of choledocholithiasis in all symptomatic patients

Timing: as early as possible in uncomplicated symptomatic cholelithiasis

45
Q

Cholecystectomy is usually not indicated in …………. cholelithiasis.

A

asymptomatic

46
Q

Nonsurgical alternatives in treatment of biliary colic Indications and procedures?

A

Indication:

  1. Patients at high risk of complications due to surgery or anesthesia (e.g., recent myocardial infarction)
  2. Patients unwilling to undergo surgery

Procedures:

  1. Expectant management
  2. Oral bile acid dissolution therapy
47
Q

Expectant management in treatment of biliary colic?

A

Expectant management : A management strategy that involves serial clinical monitoring (i.e., intermittent screening for symptoms of disease).

  1. Lifestyle modifications :
    Low-fat diet (especially low in saturated fats)
    Avoid lithogenic drugs, such as estrogen, fibrates.
    Exercise regularly.
  2. Follow-up: if symptoms recur
48
Q

Oral bile acid dissolution therapy in treatment of biliary colic pathophysiology, useful in , drug and duration ?

A

Bile acids decrease cholesterol secretion into bile → desaturation of bile → dissolution of cholesterol stones

May be useful in dissolving pure cholesterol stones (i.e., radiolucent stones) that are < 0.5 cm

Ursodeoxycholic acid

Duration of therapy: 6–24 months

49
Q

Ursodeoxycholic acid ?

A

Bile acid that inhibit intestinal absorption of cholesterol and reduce hepatic synthesis and secretion of endogenous cholesterol

50
Q

Extracorporeal shock wave lithotripsy (ESWL) in treatment of biliary colic definition and indication ?

A

Definition: a noninvasive method of stone fragmentation using an acoustic pulse in the treatment of gallstones, urolithiasis, and pancreatic stones

Indication: typically used for solitary stones that can be localized well on imaging (radiolucent)

51
Q

Extracorporeal shock wave lithotripsy (ESWL) in treatment of biliary colic procedure?

A
  1. Stones are localized using x-ray or ultrasound.
  2. A lithotriptor generates shock waves that are focused on the stone, fragmenting it in the process.
  3. Passage of stone fragments
    * Biliary stones: through the biliary system into the duodenum, If the stone fragments are too large to pass through the papilla of Vater, ESWL is be combined with endoscopic sphincterotomy to facilitate stone clearance.
    * Renal and ureteral stones: through the urinary system
    * Pancreatic stones: through the pancreatic duct into the duodenum
52
Q

Extracorporeal shock wave lithotripsy (ESWL) in treatment of biliary colic Advantage, Disadvantages and prognosis?

A

Advantage: is noninvasive and can be performed on an outpatient basis

Disadvantages
Commonly causes biliary colic
Lower success rate in the presence of multiple stones
Risk of injury to adjacent solid organs (rare)

Prognosis: high recurrence rate (between 40 and 60% within 5 years)

53
Q

Cholecystectomy definition and indication?

A

Definition
Surgical removal of the gallbladder

Indications
1. Symptomatic cholelithiasis

  1. Asymptomatic cholelithiasis with any of the following:
    * Increased risk of gallbladder cancer , E.g., gallbladder polyps ≥ 1 cm, porcelain gallbladder, gallstones ≥ 3 cm
    * Increased risk of developing complications , E.g., immunocompromised patients, multiple gallstones
    * Increased risk of becoming symptomatic , E.g., hemolytic anemia, patients undergoing gastric bypass surgery.
  2. Acute calculous cholecystitis
  3. Acalculous cholecystitis
54
Q

Cholecystectomy Contraindications?

A

Absolute: none; risks are primarily related to anesthesia

Relative

  1. Hemodynamic or respiratory instability
  2. Uncorrected coagulopathy or bleeding diathesis
  3. History of extensive abdominal surgery
  4. Cirrhosis
  5. Portal hypertension
  6. Morbid obesity
  7. Acute phase of cholangitis
55
Q

Cholecystectomy timing:
Symptomatic uncomplicated cholelithiasis?

Uncomplicated choledocholithiasis?

Complicated cholelithiasis or choledocholithiasis?

Mild biliary pancreatitis ?

Acute cholecystitis?

Acute cholangitis?

A

Symptomatic uncomplicated cholelithiasis: electively, but as early as possible

Uncomplicated choledocholithiasis: within 72 hours of ERCP-guided stone clearance

Complicated cholelithiasis or choledocholithiasis: depends on the severity of complication and the patient’s anesthesia risks

Mild biliary pancreatitis: during the same hospital admission

Acute cholecystitis
“Low-risk mild acute cholecystitis: early cholecystectomy, Surgery is performed during the same hospital admission once there are signs of resolution of the acute inflammatory process.
“High-risk or severe acute cholecystitis: interval cholecystectomy, This group of patients should be managed either conservatively with antibiotic therapy alone or with a minimally invasive procedure (gallbladder drainage) until the operative and anesthesia risks are decreased.

Acute cholangitis: ∼ 6 weeks after successful ERCP-guided stone clearance

56
Q

Cholecystectomy Approach?

A
  1. Laparoscopic cholecystectomy
    Current standard of care for most indications of cholecystectomy
  2. Open cholecystectomy
    Not routinely performed
    ** Indications include:
  3. Unsuccessful laparoscopic cholecystectomy, Converting a laparoscopic surgery to open surgery may be required in cases of uncontrollable hemorrhage, altered pericholecystic anatomy, or extensive adhesions.
  4. Gallbladder cancer
  5. As part of a bigger operative procedure that requires an open surgery, E.g., Whipple procedure, partial pancreatectomy
57
Q

Complications of cholecystectomy?

A
  1. Intraoperative and early postoperative complications
  2. Hemorrhage, Due to injury to the adjacent blood vessels (e.g., hepatic artery), slipping of the cystic artery ligature, injury to adjacent organs, or inadequate hemostasis at the time of surgery
  3. Transmural bowel injury
  4. Surgical site infection
  5. Postcholecystectomy bile leak
  6. Delayed complications
  7. Incisional hernia (at trocar site)
  8. Biliary stricture
  9. Biliary-enteric fistula
  10. Postcholecystectomy diarrhea
  11. Postcholecystectomy syndrome
58
Q

Postcholecystectomy bile leak Etiology , Clinical features and Treatment?

A

Etiology

  1. Inadequately ligated cystic duct (most common)
  2. Leak from small biliary ductules from the dissected gallbladder bed
  3. Injury to bile duct

Clinical features
Intraoperatively: golden yellow bile in the operative field
Postoperatively
Fever, abdominal pain, persistent paralytic ileus
Biliary peritonitis
Subhepatic collection → biloma or abscess

Treatment
Intraoperative diagnosis: repair of injured bile duct and/or placement of drain in the gallbladder fossa
Postoperative diagnosis: ERCP and stenting or surgical repair, depending on the severity

59
Q

Postcholecystectomy diarrhea Definition, Pathophysiology and Treatment ?

A

Definition: chronic diarrhea after removal of the gallbladder

Pathophysiology: Removal of the gallbladder → no reservoir of bile → entry of excess bile acids into the colon → secretory diarrhea

Treatment: Preferred first-line agent is cholestyramine.

60
Q

Postcholecystectomy syndrome definition , Incidence, Clinical features, diagnosis and treatment ?

A

persistent RUQ pain or new symptoms following gallbladder removal

Incidence: 10–15% of patients

Clinical features

  • Gastritis, dyspepsia, GERD, Due to excess bile entering the upper GIT. Can also be due to sphincter of Oddi dysfunction or undiagnosed preoperative PUD and GERD.
  • Postcholecystectomy diarrhea and bloating , Due to excess bile acids entering the lower GIT. Can also be due to undiagnosed IBD or IBS.
  • Jaundice and upper abdominal pain, Due to retained stone in CBD or cystic duct remnant

Diagnostics: LFT and transabdominal ultrasound are preferred initial tests

Treatment: Treat the underlying cause, in choledocholithiasis, PUD, GERD, and postcholecystectomy diarrhea. Consider ERCP and papillotomy for sphincter of Oddi dysfunction

61
Q

Complication of Cholelithiasis ?

A

A. General

  1. Cholecystitis
    * Acute cholecystitis (most common)
    * Chronic cholecystitis
    * Porcelain gallbladder
  2. Choledocholithiasis
  3. Acute cholangitis
  4. Acute biliary pancreatitis
  5. Biliary-enteric fistula

B. Complications due to gallstone impaction at the gallbladder neck or infundibulum

  1. Mirizzi syndrome
  2. Gallbladder mucocele (gallbladder hydrops)
62
Q

Biliary-enteric fistula between? Cause ?

A

Biliary-enteric fistula:
Cholecystoenteric/choledochoenteric fistula (rare), Gallstones may erode through the gallbladder or the cystic duct into the small bowel/colon.

which can cause gallstone ileus (rare), The extruded gallstone(s) may pass through the bowel without complications or may cause mechanical bowel obstruction.

63
Q

Mirizzi syndrome Definition, Clinical features and diagnosis ?

A

Definition: extrinsic compression of the common bile duct (or any extrahepatic bile duct) by gallstone(s) impacted in the cystic duct or the infundibulum of the gallbladder , Some individuals have a small outpouching of the gallbladder adjacent to the gallbladder neck, known as the Hartmann pouch of the gallbladder, in which gallstones can become impacted, leading to Mirizzi syndrome.

Clinical features: similar to choledocholithiasis

Diagnostics: preferably ERCP/MRCP

  • Narrowing of the common hepatic duct
  • Stone within the cystic duct
  • Dilation of the intrahepatic biliary tree
64
Q

Mirizzi syndrome treatment and complication?

A

Treatment

  1. ERCP-guided CBD stent placement may be considered preoperatively to allow for biliary drainage.
  2. Open cholecystectomy may be preferred if diagnosed preoperatively.

Complications
1. Cholecystocholedochal fistula: an abnormal communication between the gallbladder and the common bile duct

  1. Cholecystoenteric/choledochoenteric fistula (biliary-enteric fistula): an abnormal communication between the gallbladder or the CBD with the adjacent bowel
  2. Gallstone ileus: due to biliary-enteric fistula
65
Q

Gallbladder mucocele (gallbladder hydrops) Definition, Etiology and Pathophysiology?

A

Definition: marked distension of the gallbladder with sterile mucinous content due to chronic biliary outflow obstruction

Etiology

  1. Impacted gallstone at the gallbladder neck (most common)
  2. Resolved acute cholecystitis
  3. Tumors at the gallbladder neck or CBD (e.g., GB polyps, cholangiocarcinoma, carcinoma of pancreatic head)
  4. Acute inflammatory conditions (e.g., Kawasaki disease)
  5. Extrinsic compression of the biliary outflow tract (e.g., lymphadenopathy, adhesions, strictures)

Pathophysiology: chronic biliary outflow obstruction → resorption of bile and secretion of mucin by biliary mucosa → collection of mucinous secretion within the gallbladder with no outflow → gross distension of the gallbladder

Surgery (2 decks)

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