Gallbladder

Question 1

Acute cholecystitis pathophysiology

Answer 1

-Obstruction of gallbladder neck or cystic duct by gallstone
=Obstruction: mucus, parasitic worms, biliary tumour, follow endoscopic bile duct stenting

Initial inflammation chemically induced
=Gallbladder mucosal damage releases phospholipase
=Converts biliary lecithin to lysolecithin (toxin)
=Infection occurs eventually

Question 2

Emphysematous cholecystitis

Answer 2

-Severe infection of the gallbladder with gas-forming organisms
=elderly patients/ diabetes mellitus

Question 3

Acalculous cholecystitis

Answer 3

-Intensive care setting
-In association with parenteral nutrition, sickle cell disease and DM

Question 4

Clinical features of acute cholecystitis

Answer 4

-Pain in upper right quadrant/ epigastrium/ right shoulder tip/ intrascapular region
-Severe and prolonged pain, fever, leukocytosis

-Hypochondrial tenderness, rigidity worse on inspiration (Murphy’s sign), occasionally gallbladder mass
-Fever present, rigors unusual
-Jaundice (less than 10%, due to passage of stones into common bile duct/ compression or stricturing of common bile duct following stone impaction in cystic duct= Mirizzi’s syndrome)

Question 5

Investigations in acute cholecystitis

Answer 5

-Peripheral blood leukocytosis common (elderly= minimal signs of inflammation)
-Minor increase in transaminase and amylase
=Amylase detects acute pancreatitis (serious complications of gallstones- 1000U/L)
-AXR= radio-opaque gallstones
-Ultrasound= gallstones and gallbladder thickening
-Gallbladder empyema or perforation assessed by CT

Question 6

Medical management of acute cholecystitis

Answer 6

-Bed rest
-Pain relief (NSAIDs/ opiates
-Antibiotics (cephalosporin/ tazobactam, metronidazole in severely ill patients)
-IV fluids
-Nasogastric aspiration needed only for persistent vomiting

Question 7

Surgical management of acute cholecystitis

Answer 7

-Progresses in spite of medical management/ empyema or perforation occurs
-Within 5 days of symptom onset
=Cholecystectomy
=Percutaneous gallbladder drainage (extensive inflammatory changes)

Question 8

Chronic cholecystitis

Answer 8

-Associated with gallstones
-Recurrent attacks of upper abdominal pain, often at night and following heavy meal
Milder clinical features of acute calculous cholecystitis
-Can recover spontaneously or following analgesia and antibiotics
-Elective laparoscopic cholecystectomy

Question 9

Acute cholangitis

Answer 9

-Bacterial infection of bile ducts
-Patients with other biliary problems (choledocholithiasis, biliary strictures or tumours or ERCP)
-Jaundice, fevers (+/- rigors), RUQ pain= Charcot’s triad
-Antibiotics, relief of biliary obstruction and removal of underlying cause

Question 10

Pathophysiology of gallstones

Answer 10

-Cholesterol or pigment stones (or mixed)
-Varying quantities of calcium salts which are radio-opaque (bilirubinate, carbonate, phosphate, palmitate)

Question 11

Risk factors and mechanisms for cholesterol gallstones

Answer 11

-Increased cholesterol secretion
=Old age
=Female
=Pregnancy
=Obesity
=Rapid weight loss

-Impaired gallbladder emptying
=Pregnancy
=Gallbladder stasis
=Fasting
=Total parenteral nutrition
=Spinal cord injury

-Decreased bile salt secretion
=Pregnancy

Question 12

Composition of black pigment gallstones

Answer 12

-Polymerised calcium bilirubinate
-Mucin glycoprotein
-Calcium phosphate
-Calcium carbonate
-Cholesterol

Question 13

Risk factors of black pigment gallstones

Answer 13

-Haemolysis
-Age
-Hepatic cirrhosis
-Ileal resection/ disease

Question 14

Composition of brown pigment gallstones

Answer 14

-Calcium bilirubinate crystals
-Mucin glycoprotein
-Cholesterol
-Calcium palmitate/ stearate

Question 15

Risk factor of brown pigment gallstones

Answer 15

-Infected bile
-Stasis

Question 16

Describe cholesterol gallstones

Answer 16

-Held in solution in bile by association with bile acids and phospholipids in micelles and vesicles
-Biliary lipoproteins role in solubilising cholesterol
-Liver produces bile containing excess cholesterol as relative deficiency of bile salts/ relative excess cholesterol (lithogenic bile)
-Abnormalities of bile salt synthesis and circulation, cholesterol secretion and gallbladder function may make production of lithogenic bile more likely

Question 17

Describe pigment stones

Answer 17

-Brown, crumbly pigment stones= bacterial or parasitic biliary infection.
=Common in the Far East, where infection allows bacterial β-glucuronidase to hydrolyse conjugated bilirubin to its free form, which then precipitates as calcium bilirubinate.

-Black: Haemolysis is important as a contributing factor for the development of black pigment stones that occur in chronic haemolytic disease

Question 18

What is biliary sludge?

Answer 18

-Gelatinous bile that contains numerous microspheroliths of calcium bilirubinate granules and cholesterol crystals, as well as glycoproteins
-Important precursor to the formation of gallstones in the majority of patients.
-Frequently formed under normal conditions but then either dissolves or is cleared by the gallbladder; only in about 15% of patients does it persist to form cholesterol stones.
-Fasting, parenteral nutrition and pregnancy are also associated with sludge formation.

Question 19

Clinical features of gallstones

Answer 19

-Asymptomatic (80%)
-Biliary colic
-Acute cholecystitis
-Chronic cholecystitis
-Pain if gallstone becomes acutely impacted in cystic duct- occurs suddenly and persists for 2hrs- 6 hrs or more= cholecystitis/ pancreatitis

Question 20

Complications of gallstones

Answer 20

-Empyema of the gallbladder
-Porcelain gallbladder
-Choledocholithiasis (gallstones migrate to common bile duct)
-Acute pancreatitis (oedema at ampulla)
-Fistulae from gallbladder to duodenum/ colon (air on x-ray)
-Pressure on/inflammation of the common hepatic duct by a gallstone in the cystic duct (Mirizzi’s syndrome)
-Gallstone ileus (intestinal obstruction 2.5cm gallstone)
-Cancer of the gallbladder

Question 21

Pathophysiology of porcelain gallbladder

Answer 21

-Mucocele may develop if there is slow distension of the gallbladder from continuous secretion of mucus
-If this material becomes infected, an empyema supervenes.
-Calcium may be secreted into the lumen of the hydropic gallbladder, causing ‘limey’ bile, and if calcium salts are precipitated in the gallbladder wall, the radiological appearance of ‘porcelain’ gallbladder results

Question 22

Investigations of gallstones

Answer 22

-Transabdominal ultrasound
-CT, MRCP and, increasingly, EUS for detecting complications of gallstones (distal bile duct stone or gallbladder empyema) but are inferior to ultrasound in defining their presence in the gallbladder.
-When recurrent attacks of otherwise unexplained acute pancreatitis occur, they may result from ‘microlithiasis’ in the gallbladder or common bile duct and are best assessed by EUS.

Question 23

Treatment of gallbladder stones

Answer 23

• Cholecystectomy: laparoscopic or open
• Oral bile acids: chenodeoxycholic or ursodeoxycholic (low rate of stone dissolution)

Question 24

Treatment of bile duct stones

Answer 24

• Lithotripsy (endoscopic or extracorporeal shock wave, ESWL)
• Endoscopic sphincterotomy and stone extraction
• Surgical bile duct exploration

Question 25

Describe choledocholithiasis

Answer 25

-Stones in the common bile duct
-Primary bile duct stones are rare but can develop within the common bile duct many years after a cholecystectomy and are sometimes related to biliary sludge arising from dysfunction of the sphincter of Oddi.
-In Far Eastern countries, primary common bile duct stones are thought to follow bacterial infection secondary to parasitic infections
-Bile duct obstruction and may be complicated by cholangitis due to secondary bacterial infection, sepsis, liver abscess and biliary stricture.

Question 26

Clinical features of choledocholithiasis

Answer 26

-Asymptomatic, may be found incidentally by operative cholangiography at cholecystectomy,
-May manifest as recurrent abdominal pain with or without jaundice.
-The pain is usually in the right upper quadrant, and fever, pruritus and dark urine may be present.
-Rigors may be a feature; jaundice is common and usually associated with pain.
-Physical examination may show the scar of a previous cholecystectomy; if the gallbladder is present, it is usually small, fibrotic and impalpable.

Question 27

Investigations of choledocholithiasis

Answer 27

-LFTs show a cholestatic pattern and there is bilirubinuria.
-If cholangitis is present, the patient usually has a leucocytosis.
-Obstruction to the common bile duct is transabdominal ultrasound
=dilated extrahepatic and intrahepatic bile ducts, together with gallbladder stones
-EUS is extremely accurate at identifying bile duct stones.
-MRCP is non-invasive and is indicated when intervention is not necessarily mandatory (e.g. the patient with possible bile duct stones but no jaundice or sepsis).

Question 28

Management of choledocholithiasis

Answer 28

-Cholangitis= analgesia, IV fluids and broad-spectrum antibiotics (cefuroxime and metronidazole)
-Blood cultures
-Urgent decompression of the biliary tree and stone removal.
-ERCP with biliary sphincterotomy and stone extraction is the treatment of choice and is successful in about 90% of patients.
-Confirmed by intraoperative cholangiography.

Question 29

Carcinoma of the gallbladder

Answer 29

-Uncommon tumour, females + 70 years.
-90% adenocarcinomas; the remainder are anaplastic or, rarely, squamous tumours.
-Gallstones present in 70–80% of cases
-Calcified gallbladder= high risk of malignant change/ gallbladder polyps over 1 cm in size =increased risk of malignancy
=Preventative cholecystectomy
-Chronic infection with Salmonella, especially in areas where typhoid is endemic, is also a risk factor.

Question 30

Clinical features of carcinoma of the gallbladder

Answer 30

-Diagnosed incidentally and is found in 1–3% of gallbladders removed at cholecystectomy for gallstone disease.
-Repeated attacks of biliary pain and, later, persistent jaundice and weight loss.
-A gallbladder mass may be palpable in the right hypochondrium.
-LFTs show cholestasis, and porcelain gallbladder may be found on X-ray.
-The tumour can be diagnosed by ultrasonography and staged by CT.

Question 31

Treatment of carcinoma of the gallbladder

Answer 31

-Surgical excision but local extension of the tumour beyond the wall of the gallbladder into the liver, lymph nodes and surrounding tissues is invariable and palliative management is usually all that can be offered.
-Survival is generally short, death typically occurring within 1 year in patients presenting with symptoms.

Question 32

Describe cholangiocarcinoma

Answer 32

-Uncommon tumour that can arise anywhere in the biliary tree, from the intrahepatic bile ducts (20–25% of cases) and the confluence of the right and left hepatic ducts at the liver hilum (50–60%) to the distal common bile duct (20%).
-Associated with gallstones, primary and secondary sclerosing cholangitis, Caroli’s disease and choledochal cysts
-Primary sclerosing cholangitis carries a lifetime risk of CCA of approximately 20%,
-Chronic biliary inflammation appears to be a common factor in the development of biliary dysplasia and cancer that is shared by all the predisposing causes.

Question 33

Clinical features and investigations of cholangiocarcinoma

Answer 33

-Obstructive jaundice.
-About 50% of patients also have upper abdominal pain and weight loss.
-CT and MRI but can be difficult to confirm in patients with sclerosing cholangitis.
-Serum levels of the tumour marker CA19-9 are elevated in up to 80% of cases, although this may occur in biliary obstruction of any cause.
-In the setting of biliary obstruction, ERCP may result in positive biliary cytology.
-Endoscopic ultrasound–fine needle aspiration (EUS-FNA) of bile duct masses is sometimes possible

Question 34

Treatment of cholangiocarcinoma

Answer 34

-Surgically in about 20% of patients, which improves 5-year survival from less than 5% to 20–40%.
-Surgery involves excision of the extrahepatic biliary tree with or without a liver resection and a Roux loop reconstruction.
-However, most patients are treated by stent insertion across the malignant biliary stricture, using endoscopic or percutaneous transhepatic techniques.
-Combination chemotherapy is increasingly used and palliation with endoscopic photodynamic therapy has provided encouraging results.

Question 35

Carcinoma at the ampulla of Vater clinical features

Answer 35

-Nearly 40% of all adenocarcinomas of the small intestine arise in relationship to the ampulla of Vater and present with pain, anaemia, vomiting and weight loss.
-Jaundice may be intermittent or persistent.

Question 36

Investigations in carcinoma at the ampulla of Vater

Answer 36

-The diagnosis is made by duodenal endoscopy and biopsy of the tumour but staging by CT/MRI and EUS is essential.
-Ampullary carcinoma must be differentiated from carcinoma of the head of the pancreas and a CCA because these last two conditions both have a worse prognosis.
-Imaging may show a ‘double duct sign’ with stricturing of both the common bile duct and pancreatic duct at the ampulla and upstream dilatation of the ducts.
-EUS is the most sensitive method of assessing and staging ampullary or periampullary tumours.

Question 37

Treatment in carcinoma at the ampulla of Vater

Answer 37

-Curative surgical treatment can be undertaken by pan­creaticoduodenectomy and the 5-year survival may be as high as 50%. If resection is impossible, palliative surgical bypass or stenting may be necessary.