Cholelithiasis Flashcards
What is cholelithiasis?
Gallstone disease: when gallstones cause symptoms or complications
What is acute cholangitis?
Infection of the biliary tree, most commonly caused by obstruction.
Blockage of common bile duct - bacterial overgrowth → can enter blood stream and cause septic shock
Aetiology of acute cholangitis?
Cholelithiasis
Iatrogenic biliary duct injury
Infection (E coli, klebsiella, enterococcus, enterobacter, parasite)
Acute/ chronic pancreatitis
Risk factors of acute cholangitis?
- Gallstones
- Family history
What is Charcot’s triad?
Set of signs and symptoms for acute cholangitis
- RUQ pain
- Fever with rigors
- Jaundice
Other signs and symptoms of acute cholangitis (excluding Charcot’s triad)?
- Tachycardia
- Hypotension
- Mild hepatomegaly
- Pale stool
- Pruritis (itchy skin often caused by dry skin)
What is Reynold’s pentad for acute cholangitis?
Charcot’s triad + shock (hypotension and tachycardia) + altered mental status/ confusion
Ix: Investigations for acute cholangitis?
FBC (elevated WBC), serum urea (elevated if severe and septic) + electrolytes, LFTs (raised GGT and ALP), amylase, CRP (raised)
ABG (if suspect sepsis)
Transabdominal USS - common bile duct stones and dilatation
ERCP
First line management for acute cholangitis?
- ABCDE
- Fluids (saline bolus fluid + maintenance fluids), AB (metronidazole + cefuroxime), analgesia
- ERCP: biliary decompression and drainage (non-operative)
Management of ongoing cholangitis?
Cholecystectomy
Potential complications of acute cholangitis?
Bile duct perforation
Sepsis
Liver abscess
Liver failure
AKI
What is cholecystitis?
Acute gallbladder inflammation; major complications of gallstones
Pathophysiology of cholecystitis?
Fixed obstruction gallstones into gallbladder neck/ cystic duct → acute inflamm of gallbladder wall → stones cause bile to become trapped in gallbladder → irritation and increases pressure in gallbladder
Aetiology/ risk factors for cholecystitis?
- Gallstones!!!
- Fat, female, forty, fertile
- OCP
- Chronic haemolytic anaemia
Signs and symptoms of cholecystitis?
- RUQ pain/ tenderness (+ ve Murphy’s sign: pain on inspiration)
- Signs of inflamm: fever and tachycardia; elevated WCC, CRP and ESR
- Palpable gallbladder
- Presence of risk factors
- Other signs: nausea, anorexia, right shoulder pain
- NB: NO JAUNDICE!! (usually)
Ix: Investigations done (and results) for cholecystitis?
- MRI/ CT if sepsis suspected; USS if sepsis not suspected
- High WCC and CRP
- Check amylase/ lipases
- Only slightly deranged LFTs
- Blood cultures (will confirm infective organism if present)
- NB: no ERCP
Ix: What may the USS show for cholecystitis?
- Dilated common bile duct = obstruction there
- Gall bladder wall thickness
- Fluid in gall bladder
Ix: Why is it important to check amylase/ lipases even when suspecting cholecystitis?
Need to rule out acute pancreatitis.
In acute pancreatitis, its levels are ususally 3x higher
What non-surgical managements are done for cholecystitis?
- Clear fluids
- IV fluids
- Analgesia
- AB: cover E.coli and enterococcus (cephalosporins: class of beta lactam ABs)
- Empyema (pus) or blockage = drainage via ERCP
What surgical management is done for cholecystitis and when is it done?
Surgical cholecystectomy
5-12 weeks later
How is the management different for if there is associated organ failure with cholecystitis?
Patient must be placed in ICU
Delay cholecystectomy
What are the potential complications of cholecystitis?
- Empyema
- Porcelain gallbladder
- Perforation
- Pancreatitis
- Sepsis
What is porcelain gallbladder?
Rare complication of cholecystitis; calcification of gallbladder wall
What is biliary colic?
Caused by an gallstone stone at neck of gallbladder (therefore risk fx, symptoms, management and treatment will all be focused on the gallstone)
Crampy abdo pain, in absence of infective features (e.g. fever/raised inflammatory markers).
What is biliary colic typically triggered by?
Consumption of fatty food
What is the aetiology/ risk factors for biliary colic?
- Fatty foods consumption
- Forty, fat (obesity), female, fertile
Pathophysiology: why is the pain in biliary colic brought on by consuming fatty foods?
CCK (cholecystokinin) released from duodenum in response to fatty foods → stimulates gallbladder contraction and relaxation of sphincter of Oddi → exacerbating.
NB: also stimulates pancreatic secretions.
Ix: Investigations done for biliary colic?
Bloods (biliary colic normally presents w no lab abnormalities. Do below to rule out cholangitis, cholecystitis, pancreatitis)
USS - look for CBD dilatation and shadowing in gallbladder
ERCP if suspected cholangitis
CXR and ECG - rule out other causes
What is the management for biliary colic?
- Analgesia, fluids and anti-emetics
- ERCP
- Lap cholecystectomy long term
What are the potential complications of biliary colic?
- Poor fat tolerance post-cholecystectomy
- Cholangitis
- Empyema
- Acute pancreatitis
- Long term - cholangiocarcinoma
