Gallbladder and billary tree Flashcards
What bile stored in Gallbladder composed of ?
70 % Bile salts 10 % Cholesterol 5 % Phospholipids 5 % Proteins 1% Bilirubin ( 98 -99 % conjugated , 1 -2 % unconjuagted ) electrolytes ex - CA2 + Bicarbonate
What are Gallstones ?
Types Causes Who is at greater risk - ethnicity - Gender
Can be made out of the contents of the Gallbladder e.g.
0 Bilirubin gallstone ( pigmented stones )
- Too much
Bilirubin -
it the
unconjugated
form that
binds.
binds with
CA to form
Calcium
BILIRUBINATE
- visible on X
ray
causes - extravascular Haemolysis - RBC broken more than usual ——-> increased UCB release ——–> increase in CB ( this increase is seen in the bile as well as for UCB ) - UCB free to bind to calcium and form the stone.
0 Cholesterol Gallstone - 75 -90 % - CANT BE SEEN ON X RAY - (But if they have enough CACO3 they cab be seen. ) - but not as common
- WOMEN AT GREATER RISK OF Cholesterols stones —– oestrogen increases formation of stones —– use of oral contraceptives containing oestrogen - increases risk
Obesity —- > increased cholesterol —> increase risk of C stone development
Rapid weight loss ——> reduced lipids ——> increased risk ( do with less phospholipoid ? )
cholesterol precipitated out and formed solid stone.
- causes - supersaturation of cholesterol in bile———–> so bile salts and phospholipoid cannot hold any more in solution ( bile salts / phospholipids help to make cholesterol more soluble in bile )———–> Cholesterol comes out of solution ( precipitates )
or
* not enough bile salts / phospholipids in solution so cholesterol not kept in solution and precipitates out.
or
Gallbladder stasis - bile sits there and cholesterol precipitates out.
Brown pigmented stones - sign of biliary tract or gallbladder infection
- present in gallbladder or bile duct.
Made up of Calcium and UCB.
- ex - bacteria invades gallbladder etc ——-> brings hydrolytic enzymes along with it———> Hydrolyse CB to UCB & hydrolyse Phospholipid ———-> UCB + CA2 = brown stone. brown because of mix of UCB + Phospholipid.
example bacterias
0 E. Coli
0 Ascaris Lumbericoides
0 Clonorcnis sinesis - endemic to
0 Asian Populations - brown stones more common in this community.
What is Acute Cholecystitis ?
Inflammation of Gallbladder —> caused by obstruction of cystic duct by gallstones.
(MOST COMMON COMPLICATION OF Cholelithiasis - presence of one or more gallstone )
gallstone in the gallbladder can be asymptomatic .
It is when then obstruct the cystic duct - it causes problems .
What is Choledocholithiasis ?
Formation of gallstones in common bile duct .
How do Biliary colic , Acute cholecystitis and Cholangitis differ ?
Biliary Colic - temporary obstruction by gallstone at neck of gallbladder
0 Presents with RUQ pain. - shorter duration , less severe ( compared to AC) vs acute cholecystitis - (> 6 hours ) -
Cholangitis - complication of gallstones - infection develops. - LIFE THREATENING
Presents with ;
- RUQ pain
- Fever /
Raised
WBC count
- Jaundice
( Charcot's
triad
Acute Cholecystitis
0 Presents with
- RUQ pain
- Fever
- Raised
WBC count
RUQ pain
Frever / EBC increased
Jaundice
Symptoms / signs of Acute Cholecystitis ?
RUQ pain
pain which may radiate to right side of shoulder , right scapular or around upper abdomen.
Fever
Vomiting
Murphy sign - on examination (O.E ) deep inspiration during palpation of RUQ exacerbates pain - halting inspiration)
- during inspiration the diaphragm moves down and we are pressing on the mid border of liver - irritates gallbladder —–> trigger pain —–> patent stops breathing in.
Complications of Gallstones ?
0 Gallstone carcinoid
0 Mucocele - mucous secreted into gallbladder
0 Chronic Cholecystitis
0 Empyema - pus in gallbladder due to infection.
0 Mirizzi’s syndrome - impacted gallstone in cystic duct compresses hepatic duct ——->(Cholestasis - interuption / bloackage to bile flow from liver ) BILE produced by liver goes backwards to liver ——–> causes obstructive jaundice
0 Perforation of gallbladder
0 Cholecystroenteric fistula (Gallbladder - duodenal fistula ) - large gallstone erodes gallbladder wall —–> fistula created into small bowel or somewhere else in Abdominal cavity.
- fistula - abnormal connection btw 2 body parts.
0 large gallstones pass through and cause gallstone ileus at terminal ileus ( Gallstone ileus )
- ileus - lack of movement in the intestine
0Gallstone Pancreatitis - gallstone blocks duct where the pancreatic + common bile duct join ——> contents of pancreatic duct cannot pass e.g autodigestion etc. - radiation of pain to back.
Backflow to liver - obstruction of common bile duct ——-> obstructive jaundice.
- obstructive jaundice - jaundice - dark urine ,pale stools.
peritonitis - inflammation of peritoneum
What is Courvoisier’s Law ?
Enlarged Gallbladder + painless jaundice ———–> more likely to be carcinoma at the head of pancreas rather than Gallstones.
Treatment of Acute Cholecystitis ?
Asymptomatic - no surgery
Symptomatic - Cholecystectomy - open / Laparoscopic
- cystic duct & artery clipped —–> incision made btw clips ( clipped to prevent spillage of contents ) —-. gallbladder safety removed.
Treatment of Acute Cholecystitis ?
Asymptomatic - no surgery
Symptomatic - Cholecystectomy - open / Laparoscopic
Laparoscopic - 3 holes made.
- cystic duct & artery clipped —–> incision made btw clips ( clipped to prevent spillage of contents ) —-. gallbladder safety removed. ——> peritoneum closed.
What is Acalculous Cholecystitis ?
Risk factors
Cholecystitis without gallstones . less common but often more serious.
ACCOUNTS FOR 5 - 10 % - OF Cholecystitis .
most often caused by biliary stasis or gallbladder ischemia .
RISK FACTORS
- critical illness
- Prolonged fasting
- Shock
- Immune deficiency
- Vasculitis ( e.g. systemic lupus erythematous , polyarteritis nodose - inflammation of small + medium sized arteries preventing them from bringing 02 to organs —–> secondary tissue ischemia. ( most commonly - KIDNEYS , SKIN , JOINTS , MUSCLES , GI TRACT)
Symptoms
- similar to Acute cholecytosis - difficult to identify as Patients may be severely ill - ITU
Unexplained fever and abdominal distention - may be only clue.
untreated can rapidly lead to gallbladder gangrene , perforation —–> sepsis , shock , peritonitis.
Differential diagnosis of Gallstones ?
0 Acute hepatitis —
0 Bile duct stricture.
0 Gallbladder polyps.
0 Gastritis
0 Gastro-oesophageal reflux disease — Dyspepsia - proven GORD.
0 Inflammatory bowel disease
0 Irritable bowel syndrome
0 Non-biliary acute pancreatitis — 0 Pancreatitis - acute.
0 Peptic ulcer disease —
Dyspepsia - proven peptic ulcer.
0 Tumours of the gallbladder, liver, stomach, gut, and pancreas
Management of Asymptomatic gallstones ?
0 Asymptomatic gallstones in gallbladder - no treatment
Prophylactic Cholecystectomy - not recommended - complications outweigh risk.
0 Asymptomatic gallstones in common bile duct - Offer bile duct clearance + Laparoscopic cholecystectomy - significant risk of serious complications e.g Cholangitis / pancreatitis.
Management of symptomatic gallstones ?
Symptomatic gallstones
0 Systemically unwell with suspected complication - ( AC , Cholangitis , pancreatitis ) - admit to hospital - emergency.
0 Patients with known gallstone + jaundice or suspicion of biliary obstruction - urgent referral to gastroenterology / surgeon.
0 All other diagnosed symptomatic gallstone disease refer for laparoscopic cholecystectomy .
- urgency of referral dependant on clinical judgement.
Secondary care options - early LC (within 1 week of diagnosis )
Symptomatic gallstone in bile duct - LC + bile duct clearance
While waiting for secondary care appointment -
PAIN RELIEF -
SEVERE PAIN
intramuscular Diclofenac 75mg , second dose after 30 mins if needed.
opioid intramuscularly e.g morphine , pethidine - if diclofenac contraindicated/ not suitable/ not working (in this case can be used with diclofenac. )
MILD - TO MODERATE INTERMITTENT PAIN
NSAID - DICLODENAC - oral / rectal
if pain not managed in primary care refer to hospital.
consider recommended low fat diet to hep with biliary pain.
Diagnosis of Gallstones /
Abdomainal ultrasound - confirm presence ( absence does not exclude their existence )
LFT - gallstone sin bile duct may result in abnormal LFT
Further investigatio n :
- MRCP - magnetic resonance cholangiopancreatography
- done if ultrasound does not detect but :
bile duct dilated
LFT abnormal
- done if ultrasound does not detect but :
- Endoscopic Ultrasound (EUS ) - MRCP - still no diagnosis.
( can also a FBC , Amylase / Lipase (pancreatitis ) , LFT , CRP , EUC - to find out what is wrong - could be something else.
