Gallbladder

Question 0

Two types gallstones

Answer 0

Cholesterol gallstones (80% in Western world)
Pigment stones

Question 1

Gallstones present in what % of population?

Answer 1

10-20%

Question 2

Cholesterol gallstones

Answer 2

Form in bile with an excess of cholestol
Due to excess cholesterol, or deficiency bile salts
Promoted by reduced gall bladder motility
Frequently multifactorial

Question 3

Risk factors cholesterol gallstones

Answer 3

Increasing age
Female
Family history
Multiparity
Obesity
Rapid weight loss
Diabetes
Liver cirrhosis

Question 4

Pigment stones

Answer 4

Bilirubin polymers and calcium bilirubinate
Pts with chronic haemolysis eg sickle cell
And in cirrhosis
May form in bile duct after cholecystectomy

Question 5

Biliary pain (colic)

Answer 5

Pain associated with temporary obstruction cystic/CBD by stone
Recurrent episodes severe constant up abdo pain
May radiate to right shoulder, right supra scapular
Often vomiting

Question 6

Biliary pain investigations

Answer 6

History, US shows gallstones
Increases serum alkaline phosphatase and bilirubin support
Absence of inflammatory features differentiates from acute cholecystitis

Question 7

Biliary pain management

Answer 7

Analgesia, elective cholecystectomy
If abnormal liver biochemistry / dilated CBD - pre-op MRCP
CBD stones removed at ERCP or with cholecystectomy

Question 8

Acute cholecystitis

Answer 8

Follows impaction of stone in cystic duct / neck of gallbladder
Rare can occur without stones - acalculous cholecystitis

Question 9

Features acute cholecystitis

Answer 9

Similar to biliary colic initially
Progression over hours to severe localised RUQ pain
Fever, tenderness, guarding on examination
Worse on inspiration - Murphy’s sign
Complications - empyema, perforation

Question 10

Investigation findings acute cholecystitis

Answer 10

Leucocytosis
Serum liver biochem may be slightly abnormal
USS - gallstones, distended GB, thickened wall - corresponds to tenderness

Question 11

Management acute cholecystitis

Answer 11

Initially conservative
Nil by mouth, fluids, analgesia, antibiotics iv
Cholecystectomy usually within 48 hours

Question 12

Chronic cholecystitis

Answer 12

Often associated with gallstones
US small shrunken GB
Cholecystectomy not indicated

Question 13

Acute cholangitis

Answer 13

Infection of biliary tree, often secondary to CBD obstruction (choledocholithiasis)
Or benign biliary stricture following surgery, pancreas cancer, cancer of bile duct (cholangiocarcinoma)

Question 14

Features acute cholangitis

Answer 14

Fever, jaundice, RUQ pain (Charcot’s triad - cholangitis)

Elderly patients may present with non specific signs

Question 15

Investigations acute cholangitis

Answer 15

Leucocytosis
30% positive blood cultures
LFT cholestatic picture - raised bilirubin, alkaline phosphatase
US - dilated CBD
ERCP = definitive investigation and will allow biliary drainage, show site, obstruction, cause, can sample bile

Question 16

Management acute cholangitis

Answer 16

Revive, volume replacement, analgesia, abx…
Relief of obstruction by biliary drainage by ERCP - stone removal, stent if needed
Cephalosporin plus metronidazole

Question 17

Common bile duct stones

Choledocholithiasis!

Answer 17

May be asymptomatic
May present just with cholestatic picture LFTs
US will show stones in GB, maybe CBD
Or use MRCP, endoscopic US