Cholelithiasis

Question 1

When do you recommend surgery for gall stones?

Answer 1

A second episodes of symptoms within 3 months of the first episode

Three episodes in a year

Question 2

What is a cholecystostomy?

Answer 2

Surgical placement of a drain to remove pus in a gallbladder empyema and sepsis in order to stabilise a patient prior to definitive cholecystectomy

Question 3

What is the normal diameter of the CBD?

Answer 3

2mm + 1mm/decade of life

Question 4

What is the classic symptomatology of biliary colic?

Answer 4

RUQ pain (+/- to back)

Typically following a fatty meal

Constant pain that eventually recedes

+/- N/V

Question 5

How do you differentiate cholecystitis from biliary colic?

Answer 5

The pain is constant and will not go away at any point, if it does go away then it’s biliary colic

Question 6

What is Charcot’s triad?

Answer 6

Fever

Jaundice

RUQ Pain

Question 7

Why do you use Abx in cholecystitis? Which ones do you use?

Answer 7

Prophylaxis

Ceftriaxone

Metronidazole

Question 8

What is the most common type of gall stone? How do they form?

Answer 8

Cholesterol

Supersaturation of cholesterol in the gall bladder in a area of stasis and precipitation into stones

Question 9

When do you operate for cholecystitis?

Answer 9

As soon as possible

Question 10

What are some US findings for cholecystitis?

Answer 10

Enlarged

Thickened wall

Stones, perhaps in Hartman’s pouch

Rule out empyema, abscess

Question 11

How might the passing of a troublesome gall stone be reflected in laboratory findings?

Answer 11

Decrease in bilirubin and liver enzymes

Question 12

How is acute cholecystitis managed?

Answer 12

It is considered a surgical emergency but can be managed conservatively with antibiotics and fluids

Question 13

For which disease is Murphy’s sign most sensitive?

Answer 13

Cholecystitis

Question 14

What are some symptoms of cholecystitis?

Answer 14

Constant (>12 hours) RUQ pain

Fever

Question 15

How does the pain of biliary colic and cholecystitis differ?

Answer 15

Biliary colic pain is less well localised and not accompanied by tenderness and guarding

Cholecystitis pain is well localised to the RUQ and often accompanied by tenderness and guarding

Question 16

Why doesn’t Xray play a role in choleliathiasis?

Answer 16

Only 10-30% of cholesterol and pigment stones are radio-opaque

Question 17

How do you managed cholecystitis non-surgically?

Answer 17

Abx

Anti-pyretics

Analgesia

Cholecystostomy (radiological drainage of GB)

Question 18

Which cholelithiasis related condition presents with painless jaundice and an obstructive picture on liver enzymes?

Answer 18

Choledocholithiasis

Question 19

What is the name of the process where fluid builds up in the gallbladder secondary to an obstruction?

Answer 19

Mucocele

Question 20

What is gallstone ileus?

Answer 20

When a sufficiently large gall stone erodes through the wall of the gall bladder and travels into the duodenum down and blocks the ileum

Question 21

What is chronic cholecystitis caused by?

Answer 21

Fibrosis and loss of the function of the gall bladder due to long term stones

Question 22

What are some symptoms of gall stones?

Answer 22

RUQ pain

Anorexia

N/V

Question 23

What is unique about cholangitis?

Answer 23

Rigors

Question 24

What percentage of people have gall stones in their lifetime? What percentage of those get symptoms?

Answer 24

20%

1-4%

Question 25

How is choleliathiasis managed?

Answer 25

Medically - bile salt therapy - Dissolution - Ursodeoxycholic acid Surgery - Cholecystectomy - for patients with symptomatic disease or asymptomatic if they're at high risk of not tolerating complications Endoscopic retrograde sphincterotomy

Question 26

How does cholangitis typically present on hx?

Answer 26

Charcot's triad: Fever Jaundice RUQ pain - can radiate to the tip of the shoulder

Question 27

What type of inflammation occurs in cholecystitis?

Answer 27

Chemical inflammation

Question 28

What are some DDx of cholelithiasis complications?

Answer 28

Pancreatitis Peptic ulcers Hepatitis Appendicitis Malignancy of surrounding viscera

Question 29

What are some factors that predispose one to developing cholelithiasis?

Answer 29

Female, fat, forties, and fertile Hyperlipidaemia and hypercholesterolaemia FHx Increasing age Cholestatis - spinal cord injury

Question 30

How does pancreatitis pain differ from cholelithiasis related pain?

Answer 30

It is more severe Epigastric, sometime radiating to the back Sharp and continuous

Question 31

What are some definitive treatment methods for cholangitis?

Answer 31

ERCP GB exploration (if performing cholecystectomy)

Question 32

Why is a CTIVC better than an MRCP?

Answer 32

Because it gives a indication of excretory function

Question 33

What is the CT used for gallbladder? When is it contraindicated?

Answer 33

CT IVC (cholangiography) Biliscopin When the bilirubin is \>30

Question 34

What are some types of gall stones?

Answer 34

Cholesterol Calcium/bilirubin

Question 35

What is Reynold's pentad?

Answer 35

Charcot's triad (fever, jaundice, RUQ pain) Shock Confusion

Question 36

When are endoscopic retrograde sphincterotomy's indicated?

Answer 36

When a cholecystectomy wouldn't be tolerated To remove gall stones left after a previous cholecystectomy

Question 37

What is the temporal cut off between biliary colic and cholecystitis?

Answer 37

6hours

Question 38

What is the course of action if a gallbladder polyp is found?

Answer 38

If 5-10mm monitor If \>10mm intervene

Question 39

What is gallstone ileus?

Answer 39

When a gallstone erodes through the bladder into the duodenum and causes obstruction, usually at the ileocaecal junction

Question 40

What are the Abx of choice for biliary infections/cholangitis?

Answer 40

Ceftriaxone + metronidazole \> Tazocin

Question 41

What is Mirizzi's syndrome?

Answer 41

CBD obstruction due to a stone in Hartmann's pouch