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Sketchy- Surgery (not in anki) > Cholelithiasis and Acute Calculous Cholecystitis > Flashcards

Cholelithiasis and Acute Calculous Cholecystitis Flashcards

1
Q

Cholelithiasis is?

A

gall stones in the gallbladder than may be asymptomatic or symptomatic and is caused by stasis or imbalance in bile composition

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2
Q

brown pigment gall stones are associated with

A

bacterial or parasitic biliary tree infection within the ducts only

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3
Q

composition of brown pigment gallstones

A

the bacteria will deconjugate bilirubin and unconjugated bilirubin will precipitate with calcium forming calcium bilirubinate

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4
Q

black pigment gallstones are associated with what conditions

A

hemolytic disorders like sickle cell, hereditary spherocytosis, G6PD deficiency.

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5
Q

what is the composition of black pigment gallstones?

A

spontaneously deconjugated bilirubin cprecipitates with calcium and forms calcium bilirubinate

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6
Q

what is the most common type of gall stone

A

yellow cholesterol stones

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7
Q

what causes yellow stones

A

supersaturation of cholesterol that impedes the dissolving capacity of bile salts

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8
Q

main causes of gall stones (pathology)

A

increased cholesterol, or increased bilirubin, or decreased bile acids, or bile stasis

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9
Q

what are the risk factors for gallstones

A

high estrogenic states

female, forty, fertile , fat, fasting

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10
Q

estrogen will increase the activity of what enzyme that plays a part in gallstone formation

A

HMG-CoA reductase

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11
Q

how is fasting a risk factor for gallstone development

A

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)

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12
Q

How can inflammatory bowel disease and malabsorption conditions lead to gall stones

A

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

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13
Q

how can fibrates cause gall stones

A

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

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14
Q

indications for cholecystectomy in asymptomtic patients

A

chronic hemolytic disorders, increased risk of gall bladder cancer, gall stone bigger than 3 cm, adenomas, porcelin gall bladder

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15
Q
A
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16
Q

what is biliary colic?

A

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

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17
Q

what is the hormone responsible for the contraction of the gall bladder

A

cholecystokinin

-pain in the cystic duct is obstructed upon contraction

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18
Q

symptomatic cholelithiasis episodes last for how long

A

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

19
Q

symptomatic cholelithiasis physical exam findings

A

typically normal labs
RUQ tenderness -minimal

20
Q

diagnosis of cholelithiasis

A

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

21
Q

supportive management in symptomatic cholelithiasis can include

A

pain control with NSAIDS, dietary modification (lower fat intake, less carbs) weight loss within limitis

22
Q

what is the definitive management of symptomatic cholelithiasis

A

elective laparoscopic cholecystectomy

23
Q

what drug may be used to determine if a patient will benefit from cholecystectomy?

A

urosodiol (ursodeoxycholic acid)

24
Q

what is acute cholecystitis?

A

inflammation, distention and infection of the gall bladder

25
Q

what is the most common cause of acute cholecystitis?

A

calculous (gallstone) blocking the cystic duct or the neck of the call bladder

can also develop without the presence of a gall stone - acalculous

26
Q

Acute cholecystitis is typically inflammatory but can become infected with what organisms

A

E. coli, Enterococcous, Klebsiella, and Enterobacter transmitted through the portal system

27
Q

Acute cholecystitis pain presents how?

A

biliary colic that does not resolve with constant RUQ pain that may refer to the right shoulder or scapula

28
Q

common symptoms of acute cholecystitis

A

n/v, biliary RUQ pain, post prandial pain after a greasy meal, fever, tachycardia, hypotension (advanced cases), guarding, rebound tenderness, leukocytosis

29
Q

what sign is present with acute cholecystitis

A

Murphy sign

cessation of inspiration while pressure is applied to the RUQ

30
Q

large elevations in transaminases, bilirubin or ALP suggests

A

choledocholithiasis (gallstone in the common bile duct)

31
Q

ultrasound in acute cholecystitis shows

A

gall bladder wall thickening, distended gall bladder, sludge, and pericholecystic fluid (edema

sonographic Murphy’s sign

32
Q

CT in acute cholecystitis can show

A

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

33
Q

what is a HIDA scan

A

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.

34
Q

supportive care options in acute cholecystitis

A

IV fluids, NPO, pain control (NSAIDS/Opiods), antibiotics until gallbladder is removed

35
Q

definitive management of acute cholecystitis

A

laparoscopic cholecystectomy within 72 hours

36
Q

what are the steps to a laparoscopic cholecystectomy

A
  1. gain access to the abdomen and insufflate
  2. identify and lift the gallbladder
  3. dissect the gallbladder from base of the liver and clear fat to identify the cystic duct and artery from callots triangle
  4. identify 2 tubular structures going to the gallbladder
  5. ligate and transect the cystic artery and cystic duct and dissect the entire gallbladder off of the rest of the liver bed
  6. remove and close the abdomen
37
Q

during a laparoscopic cholecystectomy there is an optional step called intraoperative cholangiogram which is?

A

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

38
Q

what is an alternative to laparoscopic cholecystectomy in poor surgical candidates that decompressed the gallbladder

A

image guided percutaneous cholecystostomy tube placement

39
Q

what are some complications of acute cholecystitis

A

gangrenous/necrotic gallbladder (perforation and sepsis)

perforation, abscess, peritonitis, sepsis

emphysematous cholecystitis

cholecystoenteric fistula

gallstone ileus

40
Q

what is emphysematous cholecystitis

A

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

41
Q

complications with laparoscopic cholecystectomy

A

bile duct injury, retained stone, bile leak or biloma, bleeding, infection

42
Q

what is a biloma

A

fluid collection of bile

43
Q

complication of cholelithiasis

A

gallstone pancreatitis (most common cause of pancreatitis)

44
Q

what is a cholestoenteric fistula and gallstone ileus

A

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

Sketchy- Surgery (not in anki) (6 decks)

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