Gall Bladder Flashcards
what is bile formed of
cholesterol
phospholipids
bile pigments
why do gallstones form
as a result of supersaturation of bile
what are the 3 main types of gallstones
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
common risk factors for gallstones
5 F’s; fat, female, fertile, forty and family history
haemolytic anaemia - especially in pigment stones
what is biliary colic
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
describe biliary colic
RUQ pain
sudden, dull and colicky in nature
precipitated by consumption of fatty foods
why is biliary colic precipitated by consumption of fatty foods
fatty foods stimulate the duodenum cells to release Cholecystokinin which in turn stimulates contraction of the gallbladder
what positive sign indicates cholecystitis
Murphy’s sign
clinical features of acute cholecystitis
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
difference between biliary colic and acute cholecystitis
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
lab tests in suspected cholecystitis / biliary colic
FBC and CRP - check for signs of inflammation
LFTs - raised ALP
Amylase - check for pancreatitis
urinalysis and pregnancy - exclude further conditions
imaging into suspected biliary colic/acute cholecystitis
trans-abdominal USS is first line
gold standard is a Magnetic Resonance Cholangiopancreatography (MRCP)
what is the gold standard investigation into gallstones
Magnetic Resonance Cholangiopancreatography (MRCP)
management of biliary colic
analgesia
lifestyle factors; low fat diet, weight loss, more exercise
laparoscopic cholecystectomy warranted if complication occur
management of acute cholecystitis
IV abx
analgesia and anti-emetics
laparoscopic cholecystectomy indicated within 1 week of presentation
what is bouverets syndrome
fistula formed between gall bladder and small bowel
then stone impacts into the duodenum causing a gastric outlet obstruction
what is cholangitis
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
difference between cholangitis and cholecystitis
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)
common causes of cholangitis
gallstones
pancreatitis
cholangiocarcinoma
clinical features of cholangitis
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
what is charcot’s triad and what condition is it associated with
fever, RUQ and jaundice
associated with cholangitis
what is Reynauld’s pentad and what condition is it associated with
RUQ, fever, jaundice, hypotension and confusion
associated with cholangitis
what clinical features distinguish biliary colic from acute cholecystitis from cholangitis
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
investigations and imaging for cholangitis
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
management of cholangitis
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
what is a cholangiocarcinoma and where is the most common place they form
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
what is the most common histological subtype of cholangiocarcinoma seen
adenocarcinoma
risk factors for cholangiocarcinomas
primary sclerosing cholangitis
ulcerative colitis
infective (hepatitis)
toxins
alcohol excess
diabetes
chemicals
clinical features of cholangiocarcinoma
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
imaging into suspected cholangiocarcinoma
USS first line to visualise biliary tract
MRCP is optimal method for diagnosing cholangiocarcinoma
staging then done via CT
management of cholangiocarcinoma
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)
