Gall bladder

Question 1

What artery supplies the gallbladder?

Answer 1

Cystic artery, a branch of the right hepatic

Question 2

Which structures form the common bile duct?

Answer 2

Common hepatic duct and the cystic duct

Question 3

What is Hartmann’s pouch?

Answer 3

Diltation of the gallbladder outlet adjacent to the origin of the cystic duct, in which gallstones frequently become impacted

Question 4

What is the purpose of bile salts?

Answer 4

Excretion of cholesterol (which is water-insoluble) and emulsification of fat

Question 5

Where are bile salts reabsorbed from?

Answer 5

The terminal ileum, then to the liver

Question 6

What does the gallbladder contract in response to and what stimulates this?

Answer 6

Cholecystikinin, which is released from duodenal mucosa in the presence of food (especially fatty acids)

Question 7

Which process accompanies gallbladder contraction?

Answer 7

Sphincter of Oddi relaxation

Question 8

Commonest cause of prolonged jaundice in infancy?

Answer 8

Biliary atresia- failure of development of the duct system, in every 20-30k live births

Question 9

What is the cause of gallstones in most cases?

Answer 9

Excess of cholesterol excretion

Question 10

Other than excess cholesterol excretion, what predisposes to gallstones?

Answer 10

Chronic haemolysis- predisposes to pigment stone formation

Question 11

What are the potential pathological sequelae of gallstones?

Answer 11

Acute cholecystitis
Chronic cholecystitis
Gallstone ileus (if they enter the intestine)
Choledocholithiasis (if they enter the CBD)

Question 12

Why does gallstone ileus rarely occur?

Answer 12

Stones that are able to pass through the ampulla of Vater are rarely big enough to obstruct the intestine

Question 13

How are the majority of patients with gallstones affected?

Answer 13

Asymptomatic, or vague symptoms of bloating/flatulence

Question 14

Presentation of biliary colic? (4)

Answer 14

Severe epigastric/right hypochondrial pain, radiating to back
Often worse after meals/in evening
Continuous but waxing/waning
Vomiting is common

Question 15

What may happen if gallbladder obstruction does not resolve in a patient with biliary colic?

Answer 15

Acute cholecystitis

Question 16

Signs associated with acute cholecystitis?

Answer 16

Pyrexia, tachycardia, tenderness and rigidity over the gallbladder
Murphy’s sign- catching of the breath at maximal inspiration while RUQ is palpated

Question 17

In acute cholecystitis, what does the formation of a tender mass with pyrexia and rigors signal?

Answer 17

The formation of an empyema

Question 18

DDx of acute cholecystitis? (6)

Answer 18

Acute pancreatitis
Perforated peptic ulcer
Myocardial ischaemia/infarction
Basal pneumonia
Appendicitis
Ruptured ectopic pregnancy

Question 19

Antibiotic therapy for biliary tree infection?

Answer 19

Amox met gent, stepping down to met + co-amoxiclav

Question 20

Jaundice, pale stools and dark urine in patient with known gallstones?

Answer 20

Impaction of a stone in the common bile duct

Question 21

What causes cholangitis and what are the features?

Answer 21

Infection of an obstructed biliary tract

Charcot’s triad- pain, pyrexia and jaundice

Question 22

Investigations in suspected gallstones?

Answer 22

Ultrasound

MRCP

Question 23

Procedure for removal of gallstones from the common bile duct?

Answer 23

ERCP

Question 24

Surgical treatment of gallstones?

Answer 24

Laparoscopic or open cholecystectomy

Question 25

Complications of bile leakage in cholecystectomy?

Answer 25

Abnormal LFTs, abdominal pain

Question 26

Complications of cholecystectomy? (3)

Answer 26

Bile leakage Bile duct stricture leading to obstruction, possibly cholangitis Post-cholecystectomy syndrome

Question 27

Condition associated with ulcerative colitis, where both intrahepatic and extrahepatic bile ducts are inflamed

Answer 27

Primary sclerosing cholangitis

Question 28

Consequences of primary sclerosing cholangitis?

Answer 28

Bile duct carcinoma Bacterial cholangitis Secondary biliary cirrhosis

Question 29

What is the only curative treatment for PSC?

Answer 29

Liver transplant

Question 30

Why can sickle cell disease precipitate cholecystitis?

Answer 30

Increased haemolysis leading to hyperbilirubinaemia causing formation of pigment stones