Gall Bladder Flashcards
What are risk factors for developing gallstones?
high fat diet, obesity pregnant female family history age >40
Why do gallstones form?
abnormal bile composition
bile stasis
What are the main components of gall stones?
cholesterol
pigment - bilirubin
an excess of either leads to gall stones
What is biliary colic?
gallbladder neck/cystic duct impacted by a gallstone
contraction of gall bladder around stone causes pain
no inflammatory response
What are the clinical features of biliary colic?
RUQ pain (colicky), radiates to shoulder/back
nausea, indigestion
pain precipitated by eating (esp. fatty foods)
Why does eating fatty foods precipitate biliary colic?
fatty acids - duodenum releases CKK
gall bladder contracts (round the stone)
What is acute cholescystitis?
inflammation in gall bladder - obstruction of cystic duct
initially sterile- becomes infected
What are the clniical features of acute cholecystitis?
RUQ pain
signs of inflammation - fever, lethargy
O/E: tender RUQ, Murphy’s sign positive
What is Murphy’s sign?
apply pressure on RUQ and get patient to inspire - positive if halt in inspiration due to pain
What are investigations for biliary colic and cholecystitis?
blood tests:
- FBC and CRP (raised in cholecystitis)
- LFTs - raised ALP (ductal occlusion)
- amylase - pancreatitis?
imaging:
- USS: presence of stones, gallbladder wall thickness from inflammation, bile duct dilatation - stone in distal bile ducts
- MRCP - magnetic resonce cholangiopancreatography
What is the management of biliary colic?
analgesia
lifestyle factors: weight loss, low fat diet, exercise
ERCP
elective lap chole. (development of complications)
What are complications of ERCP?
perforation
bleeding
pancreatitis
What treatments can be done via ERCP?
stone removal
stenting
sphincterotomy
What is the management of acute cholecystitis?
IV antibiotics, analgesia, antiemetic
NBM
lap chole
What are the complications of lap chole?
infection, bleeding
injury to CBD
conversion to open operation
What are the complications of gallstones?
acute pancreatitis - gallstones or ERCP can cause cholangitis Mirizzi syndrome GB empyema Gallstone ileus
What is a gallstone ileus?
gallstones pass into small bowel via cholecystoduodenal fistula
bowel obstruction, usually in terminal ileum
What is a gallbladder empyema?
gall bladder filled with pus
patients are often septic
USS/CT then lap chole
What is Mirizzi syndrome?
stone in Hartmaan’s pouch or cystic duct - compression of adjacent common hepatic duct
causing obstructive jaundice
What is ascending cholangitis?
infection of the biliary tract
biliary outflow obstruction + biliary infection
What causes ascending cholangitis?
anything causing occlusion of the biliary tree
- gallstones
- ERCP
- cholangiocarcinoma
How does ascending cholangitis present?
Charcot’s triad
- RUQ pain
- fever
- jaundice (pale stool, dark urine)
How is ascending cholangitis diagnosed?
LFTs - obstructive jaundice picture
USS - bile duct dilatation, gall stones
ERCP - diagnostic and therapeutic
How is ascending cholangitis managed?
Iv access and fluid resus
manage any sepsis
broad spectrum antibiotics
ERCP (clear obstruction)
- stenting
- sphincterotomy
Where is the most common site for cholangiocarcinoma?
bifurcation of R + L hepatic ducts
What are risk factors for cholangiocarcinoma?
PSC, UC
hepatitis
HIV
alcohol excess
What are clinical features of cholangiocarcinoma?
asymp. until later stage
obstructive jaundice
pruritus
uncommon: anorexia, malaise, RUQ pain, weight loss
What are the investigations for suspected cholangiocarcinoma?
cholestatic LFTs USS - confirm obstruction MRCP/ERCP tumour marker - CA19.9 CT staging
What is the management of cholangiocarcinoma?
complete surgical resection - if early enough (majority of patients inoperative by the time they present)
radiotherapy
palliative
- radiotherapy
- stenting
- surgery - if stenting doesnt work
