Gall Stone related problems Flashcards

1
Q

What are the major components of Bile?

A
  • Bile salts (primary - cholic/ chenodeoxycholic acids; secondary - deoxy/ lithocholic acids)
  • Phospholipids (90& lecithin)
  • Cholesterol

(Admirand’s triangle)

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2
Q

How are gallstones formed?

A

Bile containing excess cholesterol relative to bile salts and lecithin predisposes to gallstone formation

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3
Q

What are the types of gallstones?

A
  • Pure cholesterole (10%, solitary large round)
  • Pure pigment (10%, bile salts, small brittle & irregular)
    1. Black (haemolytic disease)
    2. Brown (chronic cholangitis & biliary parasites)
  • Mixed (80%, multiple)
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4
Q

What are predisposing factors to gallstones?

A
  • Fat
  • Forty
  • Female
  • Fertile (multiparity/ pregnancy)
  • Chronic haemolytic disorders (pigment stones)
  • Long-term parenteral nutrition (alteration of bile constituents)
  • Previous surgery
  • Smoking
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5
Q

What is biliary colic & what is its common presentation?

A
  • 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
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6
Q

What is acute cholecystitis and what is its common presentation?

A
  • 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
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7
Q

What is mucocele and what is its common presentation?

A
  • A stone in the neck of gall bladder cause bile blockage but allowing mucous secretion
  • Large tense globular mass in RUQ
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8
Q

What is empyema?

A

Abscess of gall bladder

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9
Q

What is choledocholithiasis?

A

Gallstone migrated into bile duct

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10
Q

What are symptoms and signs of choledocholithiasis?

A
  • 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
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11
Q

What is cholangitis and what is its common presentation?

A

Biliary stasis within the common bile duct with superadded infection

Charcot’s triad (classical presentation);

  1. RUQ pain
  2. Obstructive jaundice (symptomatic choledocholithiasis)
  3. High swinging fever
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12
Q

What is Charcot’s triad?

A

Classic presentation of cholangitis;

  1. RUQ pain
  2. Obstructive jaundice (symptomatic choledocholithiasis)
  3. high swinging fever
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13
Q

What investigations would you perform in suspected stones in order to diagnose & differentiate?

A

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
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14
Q

What are the surgical treatments for gall bladder stones?

A
  • Cholecystectomy - gall bladder removal
    • Done for pretty much everyone
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15
Q

What are the non-surgical treatments for gall bladder stones?

A
  • Percutaneous drainage of gall bladder
    • Under USS or CT guidance
    • Used for empyrema if cholecystectomy unsuitable
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16
Q

What are the treatments for ductal stones?

A
  • Emergency & elective
    • ERCP with stone extraction or stent insertion