Gallbladder - Cholelithiasis, Cholecystitis, Choledocholithiasis, Cholangitis, PBS, PSC, Cholangiocarcinoma Flashcards
Cholelithiasis
-presentation
-pathophysiology
-investigations
-management
RUQ colic after fatty food => radiation to right shoulder
-CCK GB contraction
N/V
NO FEVER
DEFINITIVE Ix - Abdo USS for GS
-LFT, CRP :)
-FBC - WCC :)
-Amylase - no pancreatitis
Management
-symptomatic => elective cholecystectomy
Cholecystitis
-presentation
-pathophysiology
-investigation
-management
Constant RUQ pain => R shoulder radiation
Fever + systemic upset
Murphy’s - palpable mass
Boas - pain when post R9-11 stroked
DEFINITIVE Ix - Abdo USS for GS
-LFTs normal unless impacted in distal cystic duct causing extrinsic compression of CBD
-FBC - WCC high
-Amylase - no pancreatitis
IMMEDIATE - IV ABx, pain relief, fluids
DEFINITIVE - cholecystectomy within 1wk of diagnosis
Describe normal bilirubin metabolism
-prehepatic in the blood
-hepatic
-posthepatic
-excretion
In blood
-RBC rupture => cell contents released
-Haemoglobin => haem, globin
-Haem => biliverdin
-biliverdin => unconj bilirubin
In liver
-Unconj bilirubin => conj bilirubin => enter bile
Posthepatic
-Conj bilirubin => urobilinogen
-Some urobilinogen reabsorbed into blood => conj bilirubin
Stool
-Urobilinogen => stercobilin
Urine
-Urobilinogen => urobilin
Obstructive jaundice pathophysiology
BD Obstruction
Bilirubin backs up into liver BD
Increased hepatic pressure => Bilirubin enters the hepatic vasculature
-Bilirubin in urine=> dark
-Decreased bilirubin in stool => pale
Gall stone ileus
-presentation
-pathophysiology
-investigations
-management
SBO presentation
Repeated inflammation => fistula
-GS GB => small bowel => SBO
AXR - Rigler’s triad
-SBO - dilated bowel, plicae circularis
-GS
-pneumobilia
Laparotomy
Choledocholithiasis
-presentation
-pathophysiology
-investigations
-management
Obstructive jaundice
-CBD obstruction
-pain can be intermittent/constant
DEFINITIVE Ix - MCRP (best non invasive way to see stone)
-abdo US - CBD dilation (but ineffective for picking up stones)
-LFTs - cholestatic and hepatic
-FBC - WCC :)
DEFINTIVE Mx - ERCP BD clearance + cholecystectomy
Ascending cholangitis
-presentation
-pathophysiology
-investigations
-management
Charcots - jaundice, fever, RUQ pain
Reynolds - shock + confusion
-infected BD obstruction (typically Ecoli)
Definitive Ix - Abdo US (BD dilation, GS often hard to find)
MRCP if no stone found
-FBC, LFT, U&E, ABG - sepsis
Mx
-IMMEDIATE - ABx, fluids
-DEFINTIIVE - ERCP removal
-if caused by gallstones, may consider cholecystectomy
Describe Courvoisier’s Law
Establish cause of jaundice
-if GB palpable and non tender => unlikely to be due to stones
-repeated cholecystitis => fibrosed, contracted so cannot be felt
Could be cholangiocarcinoma, pancreatic cancer
PSC
-epidemiology and associations
-pathophysiology
-presentation
-investigations
-management
PSC - male, UC
-intra, extrahepatic BD destruction => fibrosis, cirrhosis, cholangiocarcinoma
Progressive obstructive jaundice
Investigations
Definitive - MRCP beaded
-cholestatic, pANCA AB
Management - supportive, liver transplant
PBS
-epidemiology and associations
-pathophysiology
-presentation
-investigations
-management
PBS - female, Sjogrens, scleroderma, coeliac
-intrahepatic BD destruction => fibrosis, cirrhosis, no cholangiocarcinoma
Often asymptomatic - fatigue, itch
-jaundice after years
Investigations -
Definitive - AMA AB
-cholestatic LFT
-US or MRCP to rule out other issues
Management - ursodeoxycholic acid (prevent/delay liver damage, taken for life)
Liver transplant can be considered if severe enough
Cholangiocarcinoma
-presentation
-risk factors
-investigations
-management
Persistent biliary colic symptoms
-anorexia, jaundice, weight loss
Palpable RUQ mass - Courvoisier’s sign
Periumbilical LN (Sister Mary Joseph)
Virchow node
PSC
CA19-9
LFT - cholestatic
High PT
ERCP - biopsy + close visualisation of system
Management depends on size, location, stage, general health
-surgery
-chemo, RT
-palliative stenting
