Cholelithiasis

Question 1

Risk Factors?

Answer 1

5F’s
-Female
-Fat (obese)
-Fertile, multiparous (PREGNANCY)
-Forty (increasing age)
-Family history
drugs (clifibrate (hypolipidemic drugs), ampicilin and penicilin based antibiotics)
haemolytic disease
ileal disease (ileal resection and Crohn disease)
lithogenic bile (d/t increased cholesterol content, reduced bule acids, biliary stasis)
salmonella typhi infection (typhoid)

Question 2

Types of gallstones

Answer 2

cholesterol stones （excess cholesterol）
pigment gallstone (occur with haemolysis) - hemolysis cause increase production of unconjugated bilirubin and lead to calcium bilirubinate production
mixed (calcium, pigment and cholesterol)

Question 3

Complications

Answer 3

biliary colic
cholecystitis
empyema
mucocele
carcinoma of gallbladder
perforation of gallbladder
In the ducts (obstructive jaundice, cholangitis, pancreatitis)
In the Gut (gallstone ileus ass, with cholecystoduodenal fistula)

Question 4

biliary colic symptoms?
asymptomatic?
symptomatic?

Answer 4

Asymtomatic biliary colic
dyspepsia
flatulence (perut kembung)
food intolerance 
altered bowel frequency (constipation&diarrhoea)

Symptomatic biliary colic
RUQ pain, radiating to the back
colicky, often dull and constant
severe RUQ pain, radiating to the chest
nausea
vomiting
last for minutes or even hours
wake up at night due to pain
dyspepsia

Question 5

What is biliary colic?

Answer 5

is a severe pain caused by the spasm of the gallbladder as it tries to force of a gallstone down the cystic duct
produced by impaction of stone in the neck of the gallbladder or in the cystic duct (NO INFLAMMATORY RESPONSE)
stone may either fall back into the gallbladder or pass through the CBD where the pain abates
increased the intra-gallbladder pressure
the impulses propagated via autonomic nerves
pain is produced

Question 6

MUCOCELE
Define?
S&S
Investigation
Treatment

Answer 6

Definition:
-Stone impacts the neck of the gallbladder, bile is absorbed and lead to mucus secretion

S&S

• Previous history of biliary colic
• RUQ discomfort
• feels lump
• large tense globular mass in RUQ

Investigation: USS
Treatment: Cholecystectomy

Question 7

EMPYEMA
Define
S&S
Investigation
Treatment

Answer 7

attack of cholecystitis cause infection develops after an impaction of a stone in the neck of the gallbladder. Obstruction leads to stasis, overgrowth of bacteria and the gallbladder is filled with pus

S&S

• biliary colic
• fever
• toxicity
• RUQ pain
• Tender mass in RUQ

Investigation

• WCC
• USS
• CT to look at the gas within the wall (emphysematous gallbladder)

Treatment:

• IV fluids and IV antibiotics
• managed conservatively by percutaneous drainage (cholecystostomy)
• patient too unwell then surgery

Question 8

Perforation of Gallbladder
causes?
treatment?

Answer 8

Presents as generalized biliary peritonitis or leakage of pus from a perforated empyema
Infected biliary peritonitis has a high mortality rate
most common in elderly

Treatment:
IV antibiotics
percutaneous drainage or laparotomy with peritoneal lavage
cholecystectomy

Question 9

Mirizzi Syndrome

Answer 9

A stone located in Hartmanns pouch or in the cystic duct itself which caused compression on the adjacent common hepatic duct.
Results in obstructive jaundice
Diagnosed by MRCP & laparoscopic cholecystectomy

Question 10

Bouveret’s Syndrome and Gallstone Ileus

Answer 10

inflammation of the gallbladder (recurrent) can cause a fistula form between the fundus of the gallbladder and the adjacent duodenum (Bouveret’s syndrome). A stone pass through the fistula may impact the terminal ileum causing a small bowel obstruction.