Colic, cholecystitis, gallstones Flashcards
What makes up bile?
Cholesterol
Phospholipids
Bile pigments
Where is bile stored?
Gallbladder, before passing into the duodenum upon gallbladder stimulation
What causes gallstones to form?
Supersaturation of bile by one of its components.
What are the types of gallstones?
Cholesterol stones - composed purely of cholesterol from excess cholesterol production.
Caused by female, age, obesity
Large often solitary
Pigment stones - composed purely of bile pigments from excess production.
Caused by haemolytic anaemia
Small, friable and irregular
Mixed stones - cholesterol and bile pigments and calcium salts
Faceted
What are the risk factors for gallstone disease?
Fat Female Fertile - pregnancy,OCP - oestrogen causes more cholesterol secreted into bile Forty Family hx
Pregnancy, OCP, haemolytic anaemia, malabsorption
What is biliary colic?
Gallbladder neck becomes impacted with a gallstone (cystic duct obstruction or if passed into the common bile duct)
No inflammatory response yet the contraction of the gallbladder against the occluded neck will result in pain.
Describe the pain in biliary colic
Typically sudden, dull and colicky -comes RUQ, radiates to back and epigastrium
Precipitated by consumption of fatty foods (fatty acids stimulate duodenum endocrine cells to release cholecystokinin (CCK) which stimulates gallbladder contraction.
Nausea and vomiting
What is acute cholecystitis?
Stone impaction in the neck of the gallbladder which may cause continuous epigastric pain or RUQ pain - referred to the right shoulder
Associated with. signs of inflammation - fever, tachycardia, raised WCC.
May be derangement of LFTs.
Main difference from biliary colic is the inflammatory component - local peritonism, fever raised WCC.
What sign can you test for in acute cholecystitis?
Murphy’s sign
- Ask patient to inspire while applying pressure in RUQ. If there is a halt in inspiration due to pain, Murphy’s sign is positive, indicating an inflamed gallbladder. This can be achieved more accurately with an ultrasound.
Note: only positive if same test in LUQ does not cause pain.
What are ddx for RUQ pain?
GORD
PUD
Acute pancreatitis
IBD
What might happen if the stone moves to the common bile duct following acute cholecystitis?
Jaundice and cholangitis.
What investigations for gallbladder disease?
Urinalysis (pregnancy test) to exclude renal and tubo-ovarian pathology
FBC, CRP for inflammatory response –> cholecystitis, cholangitis, pancreatitis
U&E - dehydration secondary to reduced oral fluid intake
LFT - raised ALP indicating ductal occlusion
Amylase - for pancreatitis
Imaging:
Transabdominal USS
- presence of gallstones or sludge (start of gallstone formation)
- gallbladder wall thickness (thick wall in inflamed gallbladder)
- bile duct dilatation (possible stone or stricture in distal bile duct)
Gold standard - Magnetic Resonance Cholangiopancreatography (MRCP) if USS is inconclusive
Describe management of biliary colic
Conservative
-Analgesia (NSAIDs and PRN opioid)
Antiemetic
Advise about lifestyle factors: low fat diet, weightless, increasing exercise and suitable analgesia.
Definitive:
Elective laparoscopic cholecystectomy - within 6 weeks of first presentation
Describe management of acute cholecystitis.
Conservative: Fluid resuscitation NBM and NG tube feeding if patient is vomiting Analgesia - Simple with PRN opioids Antiemetics
MEdical:
IV antibiotics - co-amoxiclav and metronidazole
Surgical:
Laparoscopic cholecystectomy within 1 week (ideally within 72 hours of presentation)
If elderly or high risk/unsuitable, percutaneous cholecytostomy to drain the infection.
Advise about lifestyle changes
How would you treat in patient with RUQ post cholecystectomy?
Check for retained common bile duct stone - US abdomen, MRCP
