Gall Stone related problems Flashcards
What are the major components of Bile?
- Bile salts (primary - cholic/ chenodeoxycholic acids; secondary - deoxy/ lithocholic acids)
- Phospholipids (90& lecithin)
- Cholesterol
(Admirand’s triangle)
How are gallstones formed?
Bile containing excess cholesterol relative to bile salts and lecithin predisposes to gallstone formation
What are the types of gallstones?
- Pure cholesterole (10%, solitary large round)
- Pure pigment (10%, bile salts, small brittle & irregular)
- Black (haemolytic disease)
- Brown (chronic cholangitis & biliary parasites)
- Mixed (80%, multiple)
What are predisposing factors to gallstones?
- Fat
- Forty
- Female
- Fertile (multiparity/ pregnancy)
- Chronic haemolytic disorders (pigment stones)
- Long-term parenteral nutrition (alteration of bile constituents)
- Previous surgery
- Smoking
What is biliary colic & what is its common presentation?
- Intermittent severe epigastric & RUQ pain
- Referred to right shoulder/ back
- Exacerbated by fatty foods
- Associated with nausea and vomiting
- Arises from impaction of gallstone in Hartmann’s pouch (cystic duct) resulting in rapid-onset
- No peritonism overlying gallbladder
- Afebrile (no fever)
- WCC, LFT and amylase normal
- USS to establish diagnosis
What is acute cholecystitis and what is its common presentation?
- Arises from impaction of gallstone in Hartmann’s pouch (cystic duct) AND presence of inflammation
- Severe continuous RUQ pain radiating to RF & back
- Associated with anorexia & pyrexia
- Gall bladder mass
- Peritonitis
- Muprhy’s sign - tenderness over gall bladder during inspiration (prove by negative on other side)
- Nausea, vomitting
- Febrile, tachycardic
Investigations
- FBC: WCC (inflammation)
- USS to establish diagnosis
- Thickened wall and shunkren gall bladder
- 6mm dilatation of CBD
- Abdo X-Ray (10% visible)
- Hepatobiliary iminodiacetic acid (HIDA) scan
What is mucocele and what is its common presentation?
- A stone in the neck of gall bladder cause bile blockage but allowing mucous secretion
- Large tense globular mass in RUQ
What is empyema?
Abscess of gall bladder
What is choledocholithiasis?
Gallstone migrated into bile duct
What are symptoms and signs of choledocholithiasis?
- Asymptomatic OR
Obstructive jaundice;
- Dark urine
- jaundice
- Pyrexia, fever, rigors & sweats suggest superadded sepsis (cholangitis)
- Increased alkaline phosphatase & bilirubin
- USS shows dilated common bile duct with gallstones
- Increased INR due to non-absorbance of vit. K
What is cholangitis and what is its common presentation?
Biliary stasis within the common bile duct with superadded infection
Charcot’s triad (classical presentation);
- RUQ pain
- Obstructive jaundice (symptomatic choledocholithiasis)
- High swinging fever
What is Charcot’s triad?
Classic presentation of cholangitis;
- RUQ pain
- Obstructive jaundice (symptomatic choledocholithiasis)
- high swinging fever
What investigations would you perform in suspected stones in order to diagnose & differentiate?
Basic tests;
- FBC (inc. WCC in cholangitis/ cholecystitis)
- LFTs (inc. conjugated bilirubin & alkaline phosphatase in duct obstruction)
- Serum amylase (gallstone pancreatitis)
- ULTRASOUND
Advanced;
- Ultrasound (transabdominal) - BEST
- MRSP (magnetic resonance cholangiopancreatography)
- For inconclusive USS
- ERCP (endoscopic retrograde cholangiopancreatography)
- Via endoscope inject radiographic contrast into the ducts which can be seen on X-Ray
- Used diagnostically if MRCP not an option
- Therapeutic interventions; Endoscopic sphincterotomy (ES) & stone extration/ destruction (lithotrypsy)
- Risks; haemorrhage, pancreatitis, infection, perforation
- PTC (percutaneous transhepatic cholangiography)
- If ERCP not available
- Risks; sepsis, tube movement, leakage, dehydration
What are the surgical treatments for gall bladder stones?
- Cholecystectomy - gall bladder removal
- Done for pretty much everyone
What are the non-surgical treatments for gall bladder stones?
- Percutaneous drainage of gall bladder
- Under USS or CT guidance
- Used for empyrema if cholecystectomy unsuitable
