Gall bladder

Question 1

Etiology (Causes)

Q: What are the common microorganisms associated with chronic calculous cholecystitis?

Answer 1

A: E. Coli, Staph, Strept, and Salmonella

Question 2

Q: How does infection typically spread to the gallbladder in chronic calculous cholecystitis?

Answer 2

A: Through direct spread or via the bloodstream.

Question 3

Q: What are some predisposing factors for developing chronic calculous cholecystitis?

Answer 3

A: Persistent predisposing factors such as gallstones, inadequate treatment of an acute attack, and a generally poor health condition.

Question 4

Pathology (Disease Process)

Q: What are some macroscopic changes observed in the gallbladder in chronic calculous cholecystitis?

Answer 4

A: The gallbladder may be deformed, the lumen may contain stones, and the wall is thickened by fibrosis (rarely calcified), with loss of peritoneal luster of the serosa.

Question 5

Q: What change is observed in the liver in chronic calculous cholecystitis?

Answer 5

A: Subcapsular fibrosis of the liver around the gallbladder bed.

Question 6

Q: What is the microscopic finding in chronic calculous cholecystitis?

Answer 6

A: Fibrous tissue and end-arteritis obliterans.

Question 7

Clinical Picture (Symptoms)

Q: What is fat (biliary) dyspepsia and how is it related to this condition?

Answer 7

A: It is indigestion related to fat intake, characterized by abdominal distention and excessive eructation (burping) after fatty meals. It is a symptom of chronic calculous cholecystitis.

Question 8

Q: Describe the characteristics of biliary pain associated with chronic calculous cholecystitis.

Answer 8

A: It is a sudden onset pain located in the right hypochondrium (upper right abdomen), often referred to the right shoulder, back, and inferior angle of the right scapula. It is often precipitated by fatty meals and relieved by antispasmodics.

Question 9

Q: What other symptoms might accompany biliary pain in severe attacks?

Answer 9

A: Nausea and vomiting.

Question 10

What can happen if the biliary pain attack persists?

Answer 10

A: It can progress to acute cholecystitis.

Question 11

Q: What is a reflex symptom sometimes associated with chronic calculous cholecystitis?

Answer 11

A: Retrosternal chest pain (pain behind the breastbone).

Question 12

Signs (Physical Examination Findings)

Q: What is Murphy’s sign and how is it elicited?

Answer 12

A: Murphy’s sign is elicited by palpating the gallbladder area while the patient takes a deep breath. A positive sign is when the patient catches their breath due to pain.

Question 13

Q: What is a common finding on physical examination in the right hypochondrium?

Answer 13

A: Tenderness.

Question 14

What is Saint’s Triad?

Answer 14

Answer: Chronic calculous cholecystitis, hiatus hernia, and diverticular disease of the colon.

Question 15

What is Wilkie’s Triad?

Answer 15

Answer: Chronic cholecystitis, chronic peptic ulcer, and chronic appendicitis.

Question 16

What is the most common cause of dyspepsia?

Answer 16

Answer: Reflux (GERD)

Question 17

What are some other causes of dyspepsia besides gallbladder issues?

Answer 17

Answer: Chronic appendicitis, chronic peptic ulcer, cancer stomach, chronic pancreatitis, hiatus hernia, and colonic dyspepsia.

Question 18

What are some general complications of gallbladder disease?

Answer 18

Answer: Chronic septic focus, toxic myocarditis, arthritis, and anemia.

Question 19

What are some local complications of gallbladder disease?

Answer 19

Answer: Acute exacerbation, gallbladder stones complications, cardiac link, porcelain gallbladder, and carcinoma of the gallbladder.

Question 20

What is the most common imaging technique for diagnosing gallbladder disease?

Answer 20

Answer: Abdominal Ultrasound

Question 21

What is the purpose of dynamic ultrasound in gallbladder assessment?

Answer 21

Answer: To detect changes in gallbladder size before and after meals and assess function.

Question 22

Why is ERCP sometimes needed in gallbladder disease?

Answer 22

Answer: To check for stones in the common bile duct (CBD) if the patient is jaundiced or has a history of jaundice.

Question 23

What is the main treatment for gallbladder disease?

Answer 23

Answer: Cholecystectomy (surgical removal of the gallbladder).

Question 24

What is porcelain gallbladder?

Answer 24

Answer: A rare condition where the gallbladder wall becomes calcified.

Question 25

What is the significance of excluding Wilkie's or Saint's Triad?

Answer 25

Answer: To ensure the correct diagnosis and appropriate treatment.

Question 26

Acute Cholecystitis What is the Etiology of Acute Cholecystitis?

Answer 26

Answer: The etiology of acute cholecystitis is primarily calcular (98%), meaning it is caused by stones in the cystic duct or Hartmann's pouch. Non-calcular causes (2%) are less common.

Question 27

What are the Microorganisms involved in Acute Cholecystitis?

Answer 27

Answer: The microorganisms usually involved in acute cholecystitis are gram-negative bacteria such as E. coli, Proteus, and Klebsiella. In some cases, Clostridium welchii or Salmonella (typhoid) can cause a more severe form called emphysematous cholecystitis.

Question 28

What are the Routes of Infection in Acute Cholecystitis?

Answer 28

Answer: The route of infection is typically through direct extension, ascending from the duodenum.

Question 29

What is the Pathogenesis of Acute Cholecystitis?

Answer 29

Answer: The pathogenesis of acute cholecystitis involves obstruction of the cystic duct or neck of the gallbladder by a stone. This obstruction leads to stasis (bile backup) and subsequent infection.

Question 30

What are the pathological findings in Acute Cholecystitis?

Answer 30

Answer: The macroscopic picture of acute cholecystitis includes a distended gallbladder with a thickened wall. The lumen may contain stones, and all layers of the gallbladder wall may show edema, hyperemia, and micro-abscesses. The mucosa may be congested with patchy ulceration, and the serosa may have lost its luster and be covered by fibrinous deposits. As a defensive mechanism, the greater omentum, duodenum, and colon may adhere to the gallbladder to localize the infection.

Question 31

What are the potential Consequences of Acute Cholecystitis?

Answer 31

Answer : The potential consequences of acute cholecystitis include resolution, persistence, recurrence, gangrene, and perforation. In most cases, with treatment, the stone dislodges, the obstruction is relieved, and the inflammation resolves gradually. However, if the condition persists, it can lead to progressive distention, empyema, thrombosis, or even gangrene. Recurrence can lead to chronic cholecystitis. Perforation is a serious complication that can lead to localized or generalized peritonitis

Question 32

Emphysematous Cholecystitis: Q: What is emphysematous cholecystitis?

Answer 32

A: It's a special, severe form of acute cholecystitis often associated with diabetes mellitus. It's caused by anaerobic organisms (like Clostridia) that produce gas within the gallbladder wall, leading to rapid gangrene.

Question 33

Clinical Picture (General Acute Cholecystitis): Q: What are the typical symptoms of acute cholecystitis?

Answer 33

A: The main symptoms include: Fever (often high). Abdominal pain: Initially diffuse and colicky in the upper abdomen, then becoming a dull, persistent ache localized to the right upper quadrant. It may refer to the right shoulder. Nausea and sometimes vomiting.

Question 34

Q: What are the key findings on physical examination in acute cholecystitis?

Answer 34

A: Key examination findings include: Fever and tachycardia. Possible jaundice (if a stone blocks the bile duct). Right hypochondrial tenderness, guarding, and rebound tenderness. A positive Murphy's sign (inspiratory arrest on palpation). Decreased bowel sounds. Boas sign (hyperesthesia between the right 9th and 11th ribs posteriorly). A gallbladder mass may be palpable, but often difficult due to tenderness and rigidity.

Question 35

What does pain persisting for more than 6 hours suggest in the context of cholecystitis?

Answer 35

A: Pain persisting for more than 6 hours is a strong indicator of acute cholecystitis.

Question 36

Differential Diagnosis (Acute Abdomen): Q: What conditions should be considered in the differential diagnosis of acute cholecystitis?

Answer 36

A: Other conditions that can mimic acute cholecystitis include: Acute appendicitis (especially with a subhepatic appendix). Acute pancreatitis. Acutely perforated duodenal ulcer. Right pyelonephritis. Amoebic hepatitis.

Question 37

What are some distinguishing features of acute pancreatitis in the differential diagnosis?

Answer 37

A: Acute pancreatitis is characterized by severe pain potentially leading to neurogenic shock, possible cyanosis and jaundice (cyano-icterus), and elevated serum amylase levels.

Question 38

Investigations: Q: What are the key laboratory findings in acute cholecystitis?

Answer 38

A: Laboratory findings may include polymorphonuclear leucocytosis (increased white blood cell count). Liver function tests (LFTs) are usually normal in uncomplicated cases.

Question 39

Q: What is the investigation of choice for diagnosing acute cholecystitis?

Answer 39

A: Ultrasound (U/S) is the investigation of choice.

Question 40

What are the typical ultrasound findings in acute cholecystitis?

Answer 40

A: Ultrasound findings may include: Stones obstructing the cystic duct (high sensitivity). Gallbladder distention. Thickened gallbladder wall. Serosal edema. Micro-abscesses within the gallbladder wall.