Cholelithiasis and Acute Calculous Cholecystitis Flashcards
Cholelithiasis is?
gall stones in the gallbladder than may be asymptomatic or symptomatic and is caused by stasis or imbalance in bile composition
brown pigment gall stones are associated with
bacterial or parasitic biliary tree infection within the ducts only
composition of brown pigment gallstones
the bacteria will deconjugate bilirubin and unconjugated bilirubin will precipitate with calcium forming calcium bilirubinate
black pigment gallstones are associated with what conditions
hemolytic disorders like sickle cell, hereditary spherocytosis, G6PD deficiency.
what is the composition of black pigment gallstones?
spontaneously deconjugated bilirubin cprecipitates with calcium and forms calcium bilirubinate
what is the most common type of gall stone
yellow cholesterol stones
what causes yellow stones
supersaturation of cholesterol that impedes the dissolving capacity of bile salts
main causes of gall stones (pathology)
increased cholesterol, or increased bilirubin, or decreased bile acids, or bile stasis
what are the risk factors for gallstones
high estrogenic states
female, forty, fertile , fat, fasting
estrogen will increase the activity of what enzyme that plays a part in gallstone formation
HMG-CoA reductase
how is fasting a risk factor for gallstone development
following a common surgery- bariatric surgery rapid weight loss can ensure and increased cholesterol metabolism and increased risk of cholesterol (yellow) gall stones
patient who are critically ill on TPN can also experience gall bladder stasis due to no CCK release and formation of cholesterol gallstones)
How can inflammatory bowel disease and malabsorption conditions lead to gall stones
inflammatory disease: impair reabsorption of bile acids at the ileum–> cholesterol stones
malabsoprtion (ileal resection)–> cant solubolize cholesterol and bile acid malabsorption can also cause pigment stones
how can fibrates cause gall stones
they decrease bile acid synthesis and can cause cholesterol call stones to form
other medications like somatostatin analogues, OCPs, ceftriaxone and hormone replacement therapy can cause gall stones as well
indications for cholecystectomy in asymptomtic patients
chronic hemolytic disorders, increased risk of gall bladder cancer, gall stone bigger than 3 cm, adenomas, porcelin gall bladder
what is biliary colic?
constant RUG or epigastric pain that is caused by the gallbladder contracting against an obstruction
pain may radiate to the R shoulder or R scapula
due to diaphragmatic irritation
what is the hormone responsible for the contraction of the gall bladder
cholecystokinin
-pain in the cystic duct is obstructed upon contraction
symptomatic cholelithiasis episodes last for how long
about 4-6 hours and then subside because the stone dislodges back into the gall bladder or passes through the cystic duct -> common bile duct -> duodenum
symptomatic cholelithiasis physical exam findings
typically normal labs
RUQ tenderness -minimal
diagnosis of cholelithiasis
ultrasound with finding of stones that are gravity dependent
hyperechoic foci with posterior acoustic shadowing
slude/liquid can also be seen
no CTs can be used because gallstones are isodense with bile
supportive management in symptomatic cholelithiasis can include
pain control with NSAIDS, dietary modification (lower fat intake, less carbs) weight loss within limitis
what is the definitive management of symptomatic cholelithiasis
elective laparoscopic cholecystectomy
what drug may be used to determine if a patient will benefit from cholecystectomy?
urosodiol (ursodeoxycholic acid)
what is acute cholecystitis?
inflammation, distention and infection of the gall bladder
what is the most common cause of acute cholecystitis?
calculous (gallstone) blocking the cystic duct or the neck of the call bladder
can also develop without the presence of a gall stone - acalculous
Acute cholecystitis is typically inflammatory but can become infected with what organisms
E. coli, Enterococcous, Klebsiella, and Enterobacter transmitted through the portal system
Acute cholecystitis pain presents how?
biliary colic that does not resolve with constant RUQ pain that may refer to the right shoulder or scapula
common symptoms of acute cholecystitis
n/v, biliary RUQ pain, post prandial pain after a greasy meal, fever, tachycardia, hypotension (advanced cases), guarding, rebound tenderness, leukocytosis
what sign is present with acute cholecystitis
Murphy sign
cessation of inspiration while pressure is applied to the RUQ
large elevations in transaminases, bilirubin or ALP suggests
choledocholithiasis (gallstone in the common bile duct)
ultrasound in acute cholecystitis shows
gall bladder wall thickening, distended gall bladder, sludge, and pericholecystic fluid (edema
sonographic Murphy’s sign
CT in acute cholecystitis can show
this imaging is less sensitive but can show fat stranding, and complications like a perforation or fistula
-gallstones may not appear due to being isodense with bile
what is a HIDA scan
a 99m technetium-labeled hepatic imilodiacetic acid scan that determines the function/filling of the gall bladder. If the scan is positive there will be no tracer in the gallbladder due to the cystic duct being blocker.
supportive care options in acute cholecystitis
IV fluids, NPO, pain control (NSAIDS/Opiods), antibiotics until gallbladder is removed
definitive management of acute cholecystitis
laparoscopic cholecystectomy within 72 hours
what are the steps to a laparoscopic cholecystectomy
- gain access to the abdomen and insufflate
- identify and lift the gallbladder
- dissect the gallbladder from base of the liver and clear fat to identify the cystic duct and artery from callots triangle
- identify 2 tubular structures going to the gallbladder
- ligate and transect the cystic artery and cystic duct and dissect the entire gallbladder off of the rest of the liver bed
- remove and close the abdomen
during a laparoscopic cholecystectomy there is an optional step called intraoperative cholangiogram which is?
this is when you inject contrast into the cystic duct and an x-ray or fluoroscopy is taken to see the biliary tree anatomy and see if there are any obstructions present
what is an alternative to laparoscopic cholecystectomy in poor surgical candidates that decompressed the gallbladder
image guided percutaneous cholecystostomy tube placement
what are some complications of acute cholecystitis
gangrenous/necrotic gallbladder (perforation and sepsis)
perforation, abscess, peritonitis, sepsis
emphysematous cholecystitis
cholecystoenteric fistula
gallstone ileus
what is emphysematous cholecystitis
gas within the gallbladder wall from an infection with a gas forming bacteria like clostridium- gas will obscure the gallbladder on ultrasound
*this requires emergency cholecystectomy
complications with laparoscopic cholecystectomy
bile duct injury, retained stone, bile leak or biloma, bleeding, infection
what is a biloma
fluid collection of bile
complication of cholelithiasis
gallstone pancreatitis (most common cause of pancreatitis)
what is a cholestoenteric fistula and gallstone ileus
a possible complication go acute cholecystitis where the gallbladder and duodenum form a fistula (track) between the two it can also cause narrowing of the ileum or ileocecal valve on the luminal side
