EXAM #3: CHOLELITHIASIS AND CHOLECYSTITIS Flashcards
What is unique about the Gallbladder in terms of its anatomy?
Enlarges as it approaches the skin
Where is the Gallbladder best found?
- Right costal margin in the mid-clavicular line
- RLQ
- Tip of right 11th rib
What is the normal function of the gallblodder?
Stores and concentrates bile
What mediates the muscular contraction and sphincter opening of the Gallbladder?
CCK (made in duodenum)
Where does Gallbladder pain radiate to?
- Right back
- Shoulder
Why does the Gallbladder pain radiate to the back and shoulder?
Viscerosomatic reflexes
What are the risk factors for gallstone formation?
1) Age
2) Female
3) Family hx
4) Native American
5) Obesity
6) Multiparity
7) Rapid weight loss
8) Hemolytic disease
9) Alcohol
10) Estrogen
11) TPN
12) Cholesterol binding resins
What are the different types of gallstones?
- Cholesterol-mixed
- Pigmented
- Sludge
- Single large
What is the composition of a cholesterol-mixed gallstones?
- Cholesterol
- Bile salts
- Lecithin
What is a pigmented gallstones composed of?
Calcium bilirubinate
What is sludge?
- Mucoprotein
- Calcium bilirubinate
- Cholesterol
What composes a single large gallstones?
Cholesterol
What causes the undulating pattern of gallbladder pain seen with gallstones?
1) CCK induced let down
2) Stone obstructs and then FALLS back
Where do gallstones commonly stick?
Common bile duct
What are the signs and symptoms of gallstones?
- RUQ pain
- Worse after eating (high fat food)
- Murphy’s sign +
What are the clinical types of cholecystitis?
- Acute
- Chronic
- Ascending cholangitis
What are the signs of acute cholecystitis?
1) Unrelenting pain
2) Fever
3) RUQ pain
4) Ass. nausea and vomiting
What are the signs of chronic cholecystitis?
Intermittent pain and well between bouts
What is Ascending Cholangitis?
Infection of the small intestine ascending into the biliary tree
What is a calculous gallstones?
US positive stone
What is an acalculous stone?
US negative for stone but positive for:
- Thickened BW wall
- Fluid in GB fossa
What is a positive sonographic Murphy’s Sign?
Murphy reproduced with US probe
What labs can be elevated in cholecystitis?
- Total bilurubin
- Lipase if obstruction leads to pancreatitis
How is cholecystitis treated?
1) NPO
2) Hydration
3) Pain control w/ Ketorolac
What warrants admission with cholecystitis?
1) Impacted stone
2) Septic
3) Unrelenting pain
4) Mimic or uncertain
What do you do if there is a negative US and clinical suspicion of gallstone?
HIDA
What is a HIDA scan?
Nuclear med. functional study of the hepatobillary tree
What are abnormal findings on a HIDA scan?
1) Non-filling i.e. obstruction
2) Non-emptying i.e. porcelain gallbladder
3) CCK sx.
What are some of the medical therapies for cholecystitis?
1) Ursodiol–decrease cholesterol absorption
2) ESWL shock waves
3) Contact dissolution
What are the quasi medical therapies for cholecystitis?
1) ERCP
2) Transcutaneous drain
What are the surgical procedures for cholecystitis?
1) Cholecystectomy
2) ERCP
What do you need to remember about the elderly and cholecystitis?
- Atypical presentation
- High mortality
List some of the conditions that mimic cholecystitis.
- Acute inferior wall MI
- Subdiaphragmatic abscess
- RLL pneumonia
- Appendicitis
- Hepatitis
- Pericarditis
- PUD
- Pancreatitis
What are the important complications of gallstones to keep in mind?
1) Gallstone ileus (Gallstone–>obstruction)
2) Gallstone pancreatitis
What is Charcot’s triad of cholangitis?
1) Jaundice
2) Fever
3) RUQ pain
What should you do if patient comes to the ED with a surgical complication?
Call the surgeon
