Gall Bladder

Question 1

what is bile formed of

Answer 1

cholesterol

phospholipids

bile pigments

Question 2

why do gallstones form

Answer 2

as a result of supersaturation of bile

Question 3

what are the 3 main types of gallstones

Answer 3

cholesterol stones - formed from excess cholesterol production

pigment stones - formed from excess bile pigments (breakdown products of haem - so often seen in people with haemolytic anaemia)

mixed stones

Question 4

common risk factors for gallstones

Answer 4

5 F’s; fat, female, fertile, forty and family history

haemolytic anaemia - especially in pigment stones

Question 5

what is biliary colic

Answer 5

pain that occurs when the gallbladder neck becomes impacted by a stone

there is no inflammatory response - but the pain is caused by the contraction of the gallbladder neck against the stone

pain is often sudden, dull and colicky and focused in the RUQ

Question 6

describe biliary colic

Answer 6

RUQ pain

sudden, dull and colicky in nature

precipitated by consumption of fatty foods

Question 7

why is biliary colic precipitated by consumption of fatty foods

Answer 7

fatty foods stimulate the duodenum cells to release Cholecystokinin which in turn stimulates contraction of the gallbladder

Question 8

what positive sign indicates cholecystitis

Answer 8

Murphy’s sign

Question 9

clinical features of acute cholecystitis

Answer 9

constant pain in RUQ associated with signs of inflammation such as fever or lethargy

tenderness in RUQ and may demonstrate a positive murphy’s sign

Question 10

difference between biliary colic and acute cholecystitis

Answer 10

biliary colic shows no signs of inflammation - pain is sudden, dull but colicky in nature

acute cholecystitis shows signs of inflammation e.g. fever, lethargy, etc. - pain is also constant rather than colicky

Question 11

lab tests in suspected cholecystitis / biliary colic

Answer 11

FBC and CRP - check for signs of inflammation

LFTs - raised ALP

Amylase - check for pancreatitis

urinalysis and pregnancy - exclude further conditions

Question 12

imaging into suspected biliary colic/acute cholecystitis

Answer 12

trans-abdominal USS is first line

gold standard is a Magnetic Resonance Cholangiopancreatography (MRCP)

Question 13

what is the gold standard investigation into gallstones

Answer 13

Magnetic Resonance Cholangiopancreatography (MRCP)

Question 14

management of biliary colic

Answer 14

analgesia

lifestyle factors; low fat diet, weight loss, more exercise

laparoscopic cholecystectomy warranted if complication occur

Question 15

management of acute cholecystitis

Answer 15

IV abx

analgesia and anti-emetics

laparoscopic cholecystectomy indicated within 1 week of presentation

Question 16

what is bouverets syndrome

Answer 16

fistula formed between gall bladder and small bowel

then stone impacts into the duodenum causing a gastric outlet obstruction

Question 17

what is cholangitis

Answer 17

infection of the biliary tract caused by a combination of biliary outflow obstruction and biliary infection, where stasis of fluid combined with elevated intraluminal pressure allows bacterial colonisation of the biliary tree

Question 18

difference between cholangitis and cholecystitis

Answer 18

cholecystitis is inflammation of the gallbladder due to obstruction of the gallbladder

cholangitis is inflammation of the biliary tree due to outflow obstruction of the biliary tract (not just the gallbladder)

Question 19

common causes of cholangitis

Answer 19

gallstones

pancreatitis

cholangiocarcinoma

Question 20

clinical features of cholangitis

Answer 20

RUQ pain, fever and jaundice (charcot’s triad) and also a raised bilirubin due to blockage

also itching (due to bilirubin accumulation) pale stool and dark urine (from obstructive jaundice)

confusion, tachycardia and hypotension may also be present

Question 21

what is charcot’s triad and what condition is it associated with

Answer 21

fever, RUQ and jaundice

associated with cholangitis

Question 22

what is Reynauld’s pentad and what condition is it associated with

Answer 22

RUQ, fever, jaundice, hypotension and confusion

associated with cholangitis

Question 23

what clinical features distinguish biliary colic from acute cholecystitis from cholangitis

Answer 23

biliary colic = RUQ colicky pain, no fever, no raised white cells and no jaundice

acute cholecystitis = RUQ pain, fever but no jaundice

cholangitis = RUQ pain, fever and jaundice

Question 24

investigations and imaging for cholangitis

Answer 24

routine bloods and LFTs - show raised WCC and raised ALP

Gold standard for cholangitis is ERCP (Endoscopic retrograde cholangiopancreatography)

first line is usually USS of biliary tract which will show bile duct dilatation

Question 25

management of cholangitis

Answer 25

treat for sepsis first as patients with cholangitis may present with sepsis

definitive management is via endoscopic biliary decompression to remove the blockage from the biliary tree

Question 26

what is a cholangiocarcinoma and where is the most common place they form

Answer 26

cancer of the biliary system

it can occur at any site along the biliary tract but most commonly occurs at the bifurcation of the right and left hepatic ducts

Question 27

what is the most common histological subtype of cholangiocarcinoma seen

Answer 27

adenocarcinoma

Question 28

risk factors for cholangiocarcinomas

Answer 28

primary sclerosing cholangitis

ulcerative colitis

infective (hepatitis)

toxins

alcohol excess

diabetes

chemicals

Question 29

clinical features of cholangiocarcinoma

Answer 29

usually asymptomatic until late stage in the disease

post-hepatic jaundice, pruritus with pale stools and dark urine, RUQ pain, weight loss and general malaise

Question 30

imaging into suspected cholangiocarcinoma

Answer 30

USS first line to visualise biliary tract

MRCP is optimal method for diagnosing cholangiocarcinoma

staging then done via CT

Question 31

management of cholangiocarcinoma

Answer 31

the only definitive cure is complete surgical resection - however only 10-15% of them are suitable for operation

most cases will only end up having palliative care (average survival is 12-18 months from diagnosis)