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Surgery - 3rd year > Gallbladder/Biliary Disease > Flashcards

Gallbladder/Biliary Disease Flashcards

1
Q

Differentials for RUQ pain

A
  • biliary colic
  • cholecystitis
  • cholangitis
  • pancreatitis
  • hepatitis
  • liver cirrhosis
  • GB empyema/gangrene/perforation

To consider: MI, peptic ulcer, UTI, RLL pneumonia

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2
Q

Gallbladder Anatomical location

A

GB lies in the right upper quadrant, under the costal margin at the level of the 9th costal cartilage

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3
Q

Bile Components (6)

A
  • Bilirubin (by-product of haeme degradation)
  • Cholesterol (kept soluble by bile salts and lecithin)
  • Bile salts (cholic acid/chenodeoxycholic acid: mostly reabsorbed in terminal ileum)
  • Lecithin (increase solubility of cholesterol)
  • Inorganic salts (sodium bicarbonate to keep bile alkaline to neutralise gastric acid in duodenum)
  • Water (97% of bile)
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4
Q

Cholelitiasis - definition

A

Cholelithiasis is the presence of solid concretions in the gallbladder. Gallstones form in the gallbladder but may exit into the bile ducts (choledocholithiasis). Symptoms ensue if a stone obstructs the cystic, bile, or pancreatic duct.

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5
Q

Types of Gallstones

A
  1. Cholesterol (90%): bile supersaturated with cholesterol, accelerated nucleation, and gallbladder hypomotility retaining this abnormal bile.
  2. Black pigment: polymerised calcium bilirubinate. RF: age, chronic haemolytic anaemia, cirrhosis, cystic fibrosis, and ileal disease
  3. Brown (mixed): result of stasis eg stricture and infection. They consist of unconjugated bilirubin and calcium salts of long-chain fatty acids
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6
Q

Gallstones - Risk factors

A
  • increasing age
  • female sex
  • obesity (BMI ≥30)
  • Native American/Hispanic ethnicity
  • positive family history
  • dietary insufficiencies
  • use of certain medications (e.g., exogenous oestrogen, octreotide, clofibrate, ceftriaxone)
  • terminal ileum disease
  • pregnancy
  • diabetes
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7
Q

Biliary colic - clinical features

A
  • suddent onset RUQ or epigastrium pain
  • lasting a few minutes to hours
  • Colicky pain, can radiate to back or shoulder tip
  • Nausea or vomiting, sweaty
  • pain relieved when stone passed through duct or re-enters gallbladder

Dyspepsia, heartburn, flatulence, and bloating are common but are not characteristic features of gallstone disease

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8
Q

Biliary colic - investigations

A
  • FBC (normal in biliary colic)
  • LFTs (normal or mildly high in biliary colic) - exclude obstructive jaundice, liver or pancreas disease
  • CRP (normal in biliary colic)
  • serum lipase and amylase - exclude pancreatitis
  • U+Es
  • abdominal US (can visualise stones)
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9
Q

Biliary colic - management

A
  • Analgesia
  • Fluids if vomiting
  • Anti-emetics if vomiting
  • usually resolves by itself
  • Admit if suspected acute cholecystitis
  • Cholecystectomy if symptomatic
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10
Q

Acute cholecystitis - definition

A
  • Acute inflammation of the gallbladder
  • Commonly gallstone stuck in cystic duct
  • A-calculus (no stones) cholecystitis rare
  • Bacterial infection in 50% only: E coli, Klebsiella, enterococci, Pseudomonas, Bacteroides fragilis
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11
Q

Acute cholecystitis - clinical features

A
  • Sudden onset RUQ pain radiate to back
  • Post-prandial, constant pain
  • Associated with nausea and vomiting
  • Recurrent attack common
  • Pyrexia
  • Murphy’s positive = palpation of the right subcostal region reveals tenderness. During deep inspiration, the tenderness suddenly becomes worse and produces inspiratory arrest.
  • peritonism RUQ (guarding, rebound tenderness)
  • small mass palpable in 30-40% cases (older pts)
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12
Q

Acute cholecystitis - investigations

A
  • FBC (high WCC - acute = neutrophils)
  • CRP (high)
  • LFTs (normal or mildly high AST/ALT)
  • ultrasound scan (pericholecystic fluid, distended gallbladder, thickened gallbladder wall, gallstones, positive Murphy’s sign)

Can consider cholescintigraphy (directly shows cystic duct obstruction) and abdominal CT
Consider erect CXR to rule out perforation (pneumoperitoneum)

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13
Q

Acute cholecystitis - management

A
  • Need admission
  • Analgesia, DVT prophylaxis
  • Intravenous fluids
  • Antibiotics (eg ciprofloxacin and metronidazole)
  • NICE now recommend early laparoscopic cholecystectomy, within 1 week of diagnosis.
  • May require CT scan to exclude complications
  • Cholecystectomy is indicated in the presence of gallbladder trauma, gallbladder cancer, acute cholecystitis, and other complications of gallstones
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14
Q

Acute cholecystitis - complications

A
  • GB Empyema
  • GB Gangrene/perforation
  • bile duct injury due to surgery
  • gallstone ileus
  • chronic cholecystitis and later on cancer
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15
Q

Complications of gallstones

A
  • (ERCP)-associated pancreatitis
  • iatrogenic bile duct injuries from cholecystectomy
  • Bouveret syndrome (gallstone erodes GB wall > cholecystoenteric fistula > duodenal obstruction)
  • gallstone ileus
  • cholecystitis
  • ascending cholangitis
  • acute biliary pancreatitis
  • Mirizzi syndrome
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16
Q

Ascending cholangitis - definition

A
  • Infection of the biliary tree, most commonly caused by obstruction due to a stone in common bile duct (normal CBD diameter < 6mm) or a stricture or after ERCP (1%).
  • Usual bugs are Klebsiella, E.Coli, Enterococci, streptococci in UK
  • also may be due to obstruction by tumours (25% of cases).
  • currently referred to as acute cholangitis or simply as cholangitis
17
Q

What is Charcot’s triad?

A

Ascending cholangitis - Charcot’s triad

  • RUQ/upper abdominal pain (diffuse and usually murphy’s sign negative)
  • Jaundice
  • Fever

(Reynald’s pentad = 3 + hypotension and confusion)

18
Q

Ascending Cholangitis - investigations

A

FBC (raised WCC)
serum urea and creatinine may be raised if severe
ABG (may have metabolic acidosis if severe)
serum LFTs (raised bilirubin, ALP and GGT)
CRP (high)
blood cultures
coagulation panel (may be prolonged with sepsis)
transabdominal ultrasound (dilated bile ducts)
MRCP (shows stones in CBD)
ERCP to treat

19
Q

Obstructive jaundice -differentials

A
  • gallstones in bile ducts
  • bile duct strictures or cysts
  • pancreatitis
  • malignancy (pancreatic, GB, bile duct, liver)
  • Primary biliary cholangitis
  • Mirizzi syndrome
20
Q

Obstructive jaundice - features

A
  • Yellow discolouration
  • Pale stool, dark urine
  • painless or assocaited with mild RUQ pain
  • No peritonism and Murphy’s -ve
  • Apyrexial, HR and BP (N)
  • WCC and CRP (N)
  • LFT: obstructive pattern bili (↑), ALP (↑), GGT (↑),
  • INR (↔ or ↑)
21
Q

Gallbladder Empyema - features

A

Acute cholecystitis in the presence of bacteria-containing bile may progress to suppurative infection
(normally cases that are left untreated and develop after a few days)
- Constant RUQ pain into back or right shoulder
- N&V, Feverish
- Tender RUQ and peritonism, Murphy’s +
- Pyrexia, HR (↑), BP (↔ or ↓)
- More septic than acute cholecystitis
- WCC and CRP (↑)
- LFT (N or mildly (↑)
- Treat with cholecystectomy or cholecystotomy (drain pus)

22
Q

Gallstone Ileus - features

A

Cholecystoenteric fistula directs stone into small bowel and can cause small bowel obstruction

Rigler’s triad

  1. pneumobilia (air in bile ducts)
  2. evidence of small bowel obstruction
  3. gallstone outside GB
  • 4 cardinal features of SBO = pain, abdominal distension, absolute constipation, vomiting
  • hyperactive/tinkling bowel sounds

Mx: laparotomy

23
Q

Mirizzi Syndrome - features

A
  • Gallstone lodged at hartmann’s pouch of GB
  • chronic inflammation and compression of CBD (fibrosis, necrosis)
  • fistulae between CBD and GB
  • pruritus (precedes jaundice), obstructive jaundice
24
Q

Primary Sclerosing Cholangitis - features

A
  • T-cell autoimmune attack (HLA predisposition)
  • ↑IgM and ↑p-ANCA
  • associated with UC
  • intra and extra hepatic fibrosis
  • beaded appearance of bile ducts due to fibrosis (onion skin) on ERCP/MRCP
  • Cx: cholangiocarcinoma; portal HTN -> HSM, cirrhosis
25
Q

Courvoisier’s law

A

Courvoisier’s law states that in the presence of jaundice and an enlarged or palpable gallbladder, malignancy of the biliary tree or pancreas should be strongly suspected as the cause is unlikely to be gallstones. This sign may be present only if the obstructing tumour is distal to the cystic duct.

26
Q

Cholangiocarcinoma

A
  • risk factors: PSC, UC, infective, alcohol, DM
  • generally asymptomatic until a late stage: post-hepatic jaundice and pruritus, with pale stools and dark urine. Less common: RUQ pain, early satiety, weight loss, anorexia and malaise.
  • Biochemical investigations: obstructive jaundice
  • 1st scan: US
  • MRCP gold standard
  • ERCP can be used for biopsy
  • staging done with CT
  • Definitive cure for cholangiocarcinoma is complete surgical resection, yet most patients will only be suitable for palliative management (stenting or bypass procedures, palliative radiotherapy)
  • Intrahepatic or Klatskin tumours require a partial hepatectomy and reconstruction of the biliary tree. Patients with distal CBD tumours require a pancreaticoduodenectomy (Whipple’s procedure).

Surgery - 3rd year (10 decks)

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