Gall stones Flashcards
What is cholelithiasis
Prescence of gall stones
What is choledocholthiasis
Presence of gall stones in common bile duct
How do gall stones form
Imbalance between ratio of cholesterol and bile pigments in bile
Too much cholesterol - age, obesity
Too much bilirubin - haemolysis
Not enough bile salts
What is cholesterolsis
Increased cholesterol in gall bladder forming HB polyps
What are the symptoms of gall stone
Asymptomatic (30%)
Dyspepsia
Loss of appetite
Biliary colic if stone gets stuck in CBD (RUQ pain radiating to back +- jaundice + N+V)
Colic last longer than obstruction
Sympyoms when stuck in CBD Jaundice Dark urine Pale stool Pruritus Steattorhea
Exam
- Scars as laparoscopic
- HSM or palpable GP - suggest malignancy
- Murphy’s for cholecystitis
What suggests abscess
Hx RUQ pain
Swinging fever
What are the RF for gall stones
Age Female OCP Obesity DM Pregnancy Hyperlipidaemia Haemolytic anaemia Bile infection Low fibre, high fat Rapid weight loss FH IBD - terminal ileal as affects absorption of bile salt
What are the complications of gallstones
If in bile duct
- Obstructive jaundice
- Cholangitis (bile duct)
- Pancreatitis as enzymes back up
- Cirrhosis
Gall bladder / cystic duct
- Biliary colic
- Cholecystits
- Empyema
- Obstruction
- Mirizzis syndrome
- Gall stone ileus
Empyema / abscess = emergency
Peritonitis
What is Mirizzi
Gall stone in GB compresses CBD
What is gall stone ileus
Fistula between gall bladder and duodenum
Stone passes and obstructs
What are the Sx of gall stone ileus
HX gall stone
Abdominal pain
Distension
Vomit
How do you Dx gall stone ileus
Laparotomy
What are cholendochal cysts
Remove as can be cancerous
How do you Dx gall stone
What other investigations for Ddx
Blood -FBC, U+E, LFT, CRP, amylase
USS = 1st line
Standard workup
Do urinalysis, CXR and ECG for DDX
What should you always do in renal / biliary colic in men
CT KUB
Assume AAA until proven otherwise
What are signs suggesting AAA
Pulsatile and expnasile mass
Do aorta exam on every abdominal
What should you do if suspect stone in CBD
MRCP
ERCP if going to remove
Not urgent if no cholangitis
Likely to cholecystectomy after
What will stones in CBD or hepatic duct cause
Jaundice
If in cystic or gall bladder = no jaundice
How do you treat asymptomatic gall stones
Observe
What do you do if symptomatic / risk of complications
Rehydrate
NBM
Laparoscopic cholecystectomy = gold standard to remove gall bladder
What is often found at cholecystectomy
Stones in CBD
Can remove at operation or early ERCP in days following
What suggest stone in CBD
Ongoing RUQ pain / jaundice
What are other options if unfit
ORSO dissolution
UDCA
What should you do before cholecystectomy
Urinanylsis
CXR
ECG
What do you do to Dx and Rx for abscess
USS +- CT to Dx
CHolecystectomy
Drainage if unfit
Antibiotics
What are the complications of cholecystectomy
Pain Haemorrhage - cystic artery Infection DVT Bile leak Bile duct injury / stricture - stent
DDX for gall stone in CBD
AAA Stricture Mirizzi PSC Pancreatitis Pancreatic cancer HIV
What are symptoms if in CBD
Dyspepsia Jaundice RUQ Pain Dark urine / pale stool / pruriitus Steatthorea N+V Anoreixa
How do you Dx stone in CBD
LFT ALP raised Other bloods - WCC / CRP USS = shows ductal dilatation ERCP or MRCP CT can see obstructive jaundice but not stones
How do you treat stones in CBD
ERCP allow location and can do sphincterotomy / stone extraction
PTC (Percutaneous trans-hepatic cholangiogram) if can’t do this
MRCP if not going to remove stone
Follow by lap chole to remove gall bladder
What are the complications of CBD
Same as gall stone
Cholangitis and pancreatitis more likely so always treat even if asymptomatic so if found at lap chole need to remove
What is cholecystits
Inflammation of the gall bladder
What causes cholecystitis
Stone in GB
Bile builds up and gets infected
Can get without stone if intercurrent illness e.g. DM / organ failure
What are the symptoms of cholecystitis
Continuous severe epigastric pain Can be colicky Fever Rigors Vomiting Local peritonism Raised WCC / CRP GB mass Murphy = pathopneumonic No jaundice
What is Murphy
Sensation of inspiration on palpation of RUQ
What are signs of chronic cholecystitis
Dyspepsia Vague discomfort DIstension Nausea Flatulence Fat intolerance Similar to IBS
How do you Dx cholecystitis
USS = thick wall, stone, dilatation
ERCP
MRCP if not suitable but need to remove stone
Deranged LFT
How do you Rx
NBM Pain relief IV AX Fluid ERCP Lap chole within 7 days of ERCP to remove GB (don't do straight away)
What do you do for chronic
ERCP and lap chole
If symptoms persist post surgery what do you suspect
Hiatus hernia GORD IBS Peptic ulcer Chronic pancreatitis Tumour
What are the complications of cholecysitis
Obstructive jaundice and cholangitis if moves to CBD
What is cholangitis
Infection of CBD SURGICAL EMERGENCY E.coli = most common Klebsiella Usually precipitated by stone or ERCP
What are the symptoms
RUQ pain Fever JAundice Hypotension / confusion / Rigors Empyema Sepsis
What are the RF
Stone in CBD
PSC
Biliary tree dilatation
How do you Dx
USS = dilatation / stone
Raised inflammatory
ERCP within 24-48 hours
How do you Rx
IV Ax - amox, met, gent, cipro
Fluid resus
Correct coagulation
Early ERCP to relieve within 48 hours or PTC
Lap chole after as likely due to gall stones from gallbladder (within 1 week)
What should you monitor for
Pancreatits
Gent levels
When is ERCP indicated
Jaundice patient suspected as having obstruciton
Pancreatic/ biliary disease
Pancreatic malignancy requiring stent
Unknown aetiology
When is it not indicated
NO obstruction
Abdo pain
What do you give before ERCP
IV Ax to prevent cholangitis - co-amox
Stop anti-coagulant
Dicloefnac to reduce risk of pancreatitis
What is risk of ERCP
Bleeding from sphincterotomy
CHolangitis
Pancreatitis
Perforation of bile duct or duodenum
Why are gall stones symptoms worse after eating
CCK
Contraction
If patient not responding to Ax in cholangitis what should you consider
Whether collection of pus e.g. gall bladder empyema
Anatomy of biliary tree
Gall bladder into cystic duct
Liver into hepatic duct
Both join to form common bile duct
Join pancreatic duct at ampulla of Vader
How do stones cause pancreatitis
Impact lower down in CBD and blocks of pancreatic duct
When would you need to do an open cholecystectomy over a LC
Failed LC
Complications in LC
Complications of acute cholecystitis
What are complications of cholecystectomy
Intra-abdo fluid collection / haematoma
Bile leak
Pancreatitis
Jaundice due to retained CBD stone or bile duct injury
What are late complications
Strictures
What causes pigmented gallstones
Anything that causes haemolytic as increased bilirubin
