Gall Bladder Diseases Flashcards
What is cholelithiasis?
Presence of gallstones in the gallbladder.
What is choledocholithiasis?
Presence of gallstones within the biliary tract.
What are the two major types of gallstones?
Cholesterol stones (80%) and Pigment stones (20%).
What is the composition of cholesterol stones?
80% cholesterol monohydrate, calcium salt, bile pigment, fatty acid & protein.
What is the composition of black pigment stones?
Calcium bilirubinate. Associated with hemolysis, cirrhosis & alcoholism.
What is the composition of brown pigment stones?
Calcium bilirubinate & calcium palmitate. Usually seen in Asians and associated with bacterial infection, parasitic infections & biliary tract stasis.
List 5 risk factors for cholesterol gallstone formation.
Fat, Forty, Fertile, Female, Fair (Caucasian), Genetic factors, Gall bladder stasis, Rapid weight loss.
Describe the pathophysiology of cholesterol gallstone formation.
- Liver cells secrete cholesterol into bile along with phospholipid. 2. Bile salt in bile dissolves cholesterol vesicle in the gall bladder. 3. When cholesterol is in excess or bile salt/acid is deficient, the unilamellar vesicle of cholesterol is not dissolved properly. 4. When bile is supersaturated with cholesterol & cholesterol monohydrate, crystals form.
What is the pathophysiology of pigment gallstone formation?
- Bilirubin is usually in conjugated form in bile. - Unconjugated bilirubin tends to form insoluble precipitate with calcium. - In situations of high heme turnover (e.g., hemolysis or cirrhosis), there is an increase in unconjugated bilirubin.
How does bacteria contribute to brown pigment stone formation?
- Presence of bacteria in bile hydrolyzes conjugated bilirubin to unconjugated bilirubin, leading to an increase in calcium bilirubinate crystal. - Bacteria also hydrolyzes lecithin (phospholipid) to replace fatty acid, allowing palmitic acid to fatty acid that combines with calcium ion to form calcium palmitate.
What percentage of patients with gallstones are asymptomatic?
80% are asymptomatic.
What is the mnemonic for clinical presentation of symptomatic cholelithiasis? List all symptoms.
BILIARY: Bloating, Indigestion (especially after fatty meals), Localized pain (RUQ or epigastric), Intermittent colicky pain, Associated nausea/vomiting, Radiating pain (to right shoulder or back), Yellowish tinge (if complicated by cholestasis).
What are the clinical presentations of choledocholithiasis?
Jaundice, PFD (Pale Feces & Dark urine), Pruritus & Pain (RUQ pain), Fever.
What sign is used to differentiate cholelithiasis from cholecystitis?
Murphyโs sign is used to differentiate cholelithiasis from cholecystitis. Positive Murphyโs sign (inspiratory arrest on deep palpation of RUQ) is highly suggestive of cholecystitis.
What are the complications of gallstones?
- Acute cholecystitis - Acute cholangitis - Acute pancreatitis - Gall stone ileus - Cancer of the gall bladder - Choledochocholangiocarcinoma - Acute ulcer disease - Appendicitis
List the investigations for gallstone disease.
- FBC - Prothrombin time - CA19-9 - LFT - Plain abdominal X-ray - Hepatobiliary ultrasound - Endoscopic ultrasound - CT scan - MRI - Endoscopic retrograde cholangiopancreatography - Percutaneous transhepatic cholangiography
What are the treatment options for gallstones?
- Cholecystectomy (laparoscopic, laparotomy) - Common bile duct stone is treated with endoscopic papillotomy & stone extraction with laparoscopic cholecystectomy - Antibiotics (ciprofloxacin, 500mg IV every 12 hours)
What is cholecystitis?
Inflammation of the gallbladder.
What are the two types of acute cholecystitis?
Calculous (due to obstruction by gallstones) and Acalculous (due to ischemia, infection or stasis with no gallstones).
What percentage of acute cholecystitis cases are acalculous?
5-10% of acute cholecystitis cases.
What are the three types of inflammatory response in cholecystitis?
(i) Mechanical inflammation (ii) Chemical inflammation (iii) Bacterial inflammation (80-85%) โ E. coli, Klebsiella, Strep, Clostridium.
What are common causes of acalculous cholecystitis?
Ischemia, infections or stasis. Common in critically ill patients (trauma, burns), after surgery, prolonged fasting, and DM patients.
What is the pathophysiology of acute cholecystitis?
Obstruction โ Gall bladder distension โ Block blood flow & lymphatic compromise โ Mucosal ischemia โ Necrosis. Mucosal damage leads to phospholipase release & conversion to lysolecithin (toxin) โ Edema of gall bladder โ Ischemia โ Gangrene โ Perforation.
What is chronic cholecystitis?
Chronic inflammation of gallbladder, almost always associated with gallstones. Results from repeated episodes of sub-acute or acute cholecystitis or persistent mechanical irritation.
What happens to the gallbladder wall in chronic cholecystitis?
Gall bladder wall hypertrophy โ Atrophy of gall bladder โ Function loss.
What is cholangitis?
Infection and inflammation of the biliary tree.
How does cholangitis typically develop?
Usually preceded by calcium bilirubin stone โ Bile duct narrowing โ Refluxion in flow of bile which flushes bacteria โ Ascension of bacteria from duodenum โ Bile duct infection.
What are the clinical features of acute cholangitis?
- RUQ/epigastric pain - Referred to top of right shoulder - Fever, vomiting - Positive Murphy sign - Tachycardia - Mild leukocytosis.
What is Reynoldsโ Pentad?
Charcotโs triad (Jaundice, Fever, RUQ pain) + Hypotension + Altered mental status. Indicates severe acute cholangitis with higher mortality due to delayed diagnosis.
What is the difference in prevalence between calculous and acalculous cholecystitis?
Calculous cholecystitis: 90% of cases. Acalculous cholecystitis: 10% of cases.
Differentiate Calculous & Acalculous Cholecystitis
Calculous Cholecystitis
โข Cause: Gallstones blocking the cystic duct
โข Risk Factors: โFat, Female, Fertile, Fortyโ
โข Pathophysiology: Obstruction โ Bile stasis โ Inflammation
โข Prevalence: 90% of cases
Acalculous Cholecystitis
โข Cause: No gallstones; caused by ischemia
โข Risk Factors: Critically ill patients, trauma, burns, sepsis
โข Pathophysiology: Ischemia โ Bile stasis โ Inflammation
โข Prevalence: 10% of cases
What is the most common histological type of gallbladder carcinoma?
Adenocarcinoma (more than 90% of cases).
Name four risk factors for gallbladder carcinoma.
Gallstones, female gender, obesity, porcelain gallbladder.
What is the association between chronic inflammation and gallbladder carcinoma?
Chronic inflammation, such as that caused by gallstones, can lead to progressive inflammation, infection, and epithelial dysplasia, eventually resulting in adenocarcinoma.
What genetic mutations are associated with gallbladder carcinoma?
Mutations in Ras and TP53.
What are common clinical presentations of cholangiocarcinoma?
Abdominal pain, jaundice, fever, weight loss, and itching.
How does gallbladder cancer typically spread?
It can metastasize to the liver, bile duct, stomach, and duodenum.
What is the primary treatment for gallbladder carcinoma?
Surgery.
What is the 5-year survival rate for gallbladder carcinoma?
0.8
What is sclerosing cholangitis?
A progressive disease characterized by inflammation, fibrosis, and stricturing of the bile ducts, leading to cholestasis and liver damage.
Which inflammatory bowel disease is associated with sclerosing cholangitis?
Ulcerative colitis (associated in 70% of cases).
Name three microorganisms associated with sclerosing cholangitis.
Mycobacterium avium, cytomegalovirus (CMV), and Cryptosporidium.
What is a major complication of sclerosing cholangitis?
Cholangiocarcinoma (bile duct cancer).
What is the pathophysiology of sclerosing cholangitis?
Bile duct injury โ Inflammation โ Granulation tissue formation โ Stricture formation โ Duct sclerosis โ Bile duct obstruction.
What is the survival prognosis once symptoms of sclerosing cholangitis appear?
Around 10 years.
What are gallbladder polyps composed of, and what are two types?
They are composed of cholesterol deposits. The two types are adenomyomatosis and cholesterosis.
What are the complications of cholecystitis?
โฆ๏ธ Gallbladder Gangrene
โฆ๏ธ Gallbladder Rupture
โฆ๏ธEmpyema
โฆ๏ธFistula Formation
What are the treatment modalities for cholecystitis?
โฆ๏ธIV rehydration
โฆ๏ธAnalgesia
โฆ๏ธElectrolyte Correction
โฆ๏ธBroad spectrum antibiotics
โฆ๏ธCholecystectomy
What is cholesterosis?
Cholesterosis is a condition in which cholesterol esters accumulate in the macrophages of the gallbladder mucosa, leading to the formation of cholesterol-laden deposits.
What condition is often referred to as Strawberry gallbladder?
Cholesterosis
It is often referred to as โstrawberry gallbladderโ due to its characteristic yellow speckled appearance on the red mucosal background.
What is Porcelain gallbladder?
It is a condition where the gallbladder is covered by calcium deposits?
What is the capacity of the gallbladder?
50mls
What is Charcotโs triad?
Jaundice
Fever
RUQ pain
What condition presents with charcotโs triad/Raynaudโs pentad?
Cholangitis
What are the borders of the Hartmannโs pouch?
โข Superiorly: The gallbladder neck
โข Inferiorly: The body of the gallbladder
โข Medially: The cystic duct
โข Laterally: The fundus of the gallbladder
What is Mirizzi Syndrome?
Mirizzi syndrome is a rare condition in which a gallstone becomes impacted in the cystic duct or Hartmannโs pouch, leading to external compression of the common hepatic duct and causing obstructive jaundice.
Clinical features of Mirizzi syndrome?
โข Jaundice
โข Right upper quadrant pain
โข Fever
โข Elevated bilirubin and ALP
What is the Hartmannโs pouch?
Hartmannโs pouch is a small outpouching or sac-like dilatation that forms at the junction of the gallbladder neck and the cystic duct
