Gall stones Flashcards by Eilidh Seaton

What is cholelithiasis

Prescence of gall stones

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What is choledocholthiasis

Presence of gall stones in common bile duct

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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

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What is cholesterolsis

Increased cholesterol in gall bladder forming HB polyps

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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

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What suggests abscess

Hx RUQ pain

Swinging fever

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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

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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

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What is Mirizzi

Gall stone in GB compresses CBD

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What is gall stone ileus

Fistula between gall bladder and duodenum

Stone passes and obstructs

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What are the Sx of gall stone ileus

HX gall stone
Abdominal pain
Distension
Vomit

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How do you Dx gall stone ileus

Laparotomy

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What are cholendochal cysts

Remove as can be cancerous

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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

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What should you always do in renal / biliary colic in men

CT KUB

Assume AAA until proven otherwise

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What are signs suggesting AAA

Pulsatile and expnasile mass

Do aorta exam on every abdominal

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What should you do if suspect stone in CBD

MRCP
ERCP if going to remove
Not urgent if no cholangitis
Likely to cholecystectomy after

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What will stones in CBD or hepatic duct cause

Jaundice

If in cystic or gall bladder = no jaundice

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How do you treat asymptomatic gall stones

Observe

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What do you do if symptomatic / risk of complications

Rehydrate
NBM
Laparoscopic cholecystectomy = gold standard to remove gall bladder

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What is often found at cholecystectomy

Stones in CBD

Can remove at operation or early ERCP in days following

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What suggest stone in CBD

Ongoing RUQ pain / jaundice

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What are other options if unfit

ORSO dissolution

UDCA

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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