Gall Bladder: Cholelithiasis, Cholecystitis, Choledocholithiasis, Cholangitis, PBC, PSC

Question 1

Cholelithiasis

• presentation
• pathophysiology
• investigations
• management

Answer 1

RUQ colic after fatty food
-CCK GB contraction

DEFINITIVE Ix - Abdo USS for GS

• LFT :)
• FBC - WCC :)
• Amylase - no pancreatitis

Management
-symptomatic => elective cholecystectomy

Question 2

Cholecystitis

• presentation
• pathophysiology
• investigation
• management

Answer 2

Constant RUQ pain
Fever
Murphy’s - palpable mass
Boas - pain when post R9-11 stroked

DEFINITIVE Ix - Abdo USS for GS

• Cholestatic LFTs
• FBC - WCC high
• Amylase - no pancreatitis

IMMEDIATE - IV ABx, pain relief, fluids
DEFINITIVE - cholecystectomy

Question 3

Describe normal bilirubin metabolism

• prehepatic in the blood
• hepatic
• posthepatic
• excretion

Answer 3

In blood

• RBC rupture => cell contents released
• Haemoglobin => haem, globin
• Haem => biliverdin
• biliverdin => unconj bilirubin

In liver
-Unconj bilirubin => conj bilirubin => enter bile

Posthepatic

• Conj bilirubin => urobilinogen
• Some urobilinogen reabsorbed into blood => conj bilirubin

Stool
-Urobilinogen => stercobilin

Urine
-Urobilinogen => urobilin

Question 4

Obstructive jaundice pathophysiology

Answer 4

BD Obstruction
Bilirubin backs up into liver BD
Increased hepatic pressure => Bilirubin enters the hepatic vasculature

• Bilirubin in urine=> dark
• Decreased bilirubin in stool => pale

Question 5

Gall stone ileus

• presentation
• pathophysiology
• investigations
• management

Answer 5

SBO presentation
Repeated inflammation => fistula
-GS GB => small bowel => SBO

AXR - Rigler’s triad

• SBO - dilated bowel, plicae circularis
• GS
• pneumobilia

Laparotomy

Question 6

Choledocholithiasis

• presentation
• pathophysiology
• investigations
• management

Answer 6

Obstructive jaundice
-CBD obstruction

DEFINITIVE Ix - MCRP

• abdo US - CBD dilation
• LFTs - cholestatic and hepatic
• FBC - WCC :)

DEFINTIVE Mx - ERCP BD clearance + cholecystectomy

Question 7

Cholangitis

• presentation
• pathophysiology
• investigations
• management

Answer 7

Charcots - jaundice, fever, RUQ pain
Reynolds - shock + confusion
-infected BD obstruction

Definitive Ix - Abdo US (BD dilation, GS)
MRCP if no stone found
-FBC, LFT, U&E, ABG - sepsis

Mx

• IMMEDIATE - ABx, fluids
• DEFINTIIVE - ERCP removal

Question 8

Describe Courvoisier’s Law

Answer 8

Establish cause of jaundice

• if GB palpable => unlikely to be due to stones
• repeated cholecystitis => fibrosed, contracted so cannot be felt

Could be gall bladder, pancreatic cancer

Question 9

PSC

• epidemiology and associations
• pathophysiology
• presentation
• investigations
• management

Answer 9

PSC - male, UC
-intra, extrahepatic BD destruction => fibrosis, cirrhosis, cholangiocarcinoma

Progressive obstructive jaundice

Investigations - cholestatic, pANCA AB
MRCP - beaded

Management - supportive, liver transplant

Question 10

PBS

• epidemiology and associations
• pathophysiology
• presentation
• investigations
• management

Answer 10

PBS - female, Sjogrens, scleroderma, coeliac
-intrahepatic BD destruction => fibrosis, cirrhosis, no cholangiocarcinoma

Often asymptomatic - fatigue, itch
-jaundice after years

Investigations - cholestatic, AMA AB
-US or ERCP

Management - ursodeoxycholic acid