Cholelithiasis vs. Acute Cholecystitis vs. Ascending Cholangitis Flashcards
Cholelithiasis
What is it?
Types
Causes
Stone formation in the gall bladder
Types:
- Cholesterol
- Pigmented (due to too much haemolysis)
- Mixed
Causes:
- fat, female, forty. Fertile, fair
- high bilirubin e.g. haemolysis
Cholelithiasis / Gall bladder Stone / biliary colic
Clinical Features
Largely asymptomatic
Colicky pain (coming and going/ is pseudo colicky so constant) - RUQ
Pain can radiate to right shoulder tip due to parietal peritoneum over diaphragm being irritated by gallbladder which then irritate phrenic nerve and so causes referred pain
Worse when eating fatty foods - because to digest fats the gallbladder needs to secrete bile which involves the organ contracting
Nausea
Cholelithiasis / Gall bladder stones
Diagnosis
Bloods: LFTs (in 60% cases one of these will be deranged)
Ultrasound (RUQ and operator dependant showing acoustic shadowing)
If suspected to be in cystic duct then Magnetic Resonance Cholangiography
Cholelithiasis / Gall Bladder Stones
Management
Conservative: fat free diet
Medical: analgesia
Surgery:
- Only if symptomatic
- Elective Cholecystectomy
Cholecystitis
What is wrong?
Inflammation in the cystic duct due to a stone being stuck in the cystic duct or stricture or extrinsic tumour e.g. HCC
This causes stasis of bile and bacterial growth
Cholecystitis
Clinical Features
Complication
Murphy’s sign - deep breath in and doctor presses down on liver and cystic duct which irritates them = a lot of pain in RUQ
CONSTANT pain (not colicky) and radiates to shoulder tip
Nausea and vomiting
Guarding
Fever
Complication: sepsis, perforation
Cholecystitis
Investigations
Blood: leukocystitis (high WCC because inflammation)
LGTs - cholestatic picture with raised ALP and bilirubin
Amylase and CRP will also be raised
Imaging:
USS first line
If no visible stones and clinical features (abnormal LFTs or dilated CBD) do MRCP
Cholecystitis
Management
Acute: NBM
Analgesia with NSAIDs
Antiemetic
Antibiotics
Cholecystectomy (not if just symptomatic, always)
Choledocolithiasis
What is it?
stone obstruction of the common bile duct
Causing dilated hepatic bile ducts
Choledocolithiasis
Clinical Features
Obstructive jaundice (because bilirubin can’t be drained from the biliary tree so you get build up of bilirubin)
= yellowing of skin, sclera icterus, increased bilirubin
Choledocolithiasis
Diagnosis and Management
MRCP: Dx only - see if there is a stone in the biliary tree
ERCP: both Dx and Mx- scope to see biliary tree and remove stone if there is on
Ascending Cholangitis
What is it?
Where does it tend to be?
Stone in common bile duct (choledocolithiasis) + infection that ascends up the biliary tree
Stone tends to be around sphincter of odi (sphincter controlling common bile duct and pancreatic duct drainage into the duodenum)
And so bowel bacteria can ascend up the biliary tree
Cholangitis
Clinical Features
Charcot’s Triad:
- Fever (Rigors indicative of septicaemia)
- RUQ pain
- Jaundice
Which can develop into Reynold’s Pentad (essentially Charcot’s triad + shock)
- Fever
- RUQ pain
- Jaundice
- Hypotension
- Altered mental state
[Outside a REYNOLDS cafe there is a homeless man with CHARCOT’s foot due to diabetes and that causes passers-by SHOCK as they are ASCENDING the escalator]
Cholangitis
Management
NBM, IV fluids, antibiotics, analgesia
Emergency ERCP
What is Courvoisier’s Law?
Enlarged gallbladder with PAINLESS JAUNDICE
Likely to be malignancy - can be of pancreas or biliary
