Gallbladder disease Flashcards
What does bile contain
Water
Cholesterol
Bile pigments
Phospholipids
How is bile secreted by gallbladder
Bile produced in liver
Then stored and concentrated in gallbladder
Lipid rich food in duodenum stimulates CCK release which causes Gallbladder contraction. Bile passes from the hallbladder into the duodenum
What results in gallstone formation
Supersaturation of bile
factors which contribute to gallstone formation
Cholesterol supersaturation.
- Caused by increased plasma oestrogen [female, forty, fat, fair, fertile (one or more children), + fam history)
- Caused by depletion of the bile acid pool –> terminal ileum resection or disease
Stasis of bile
-Lack of stimulus to GB emptying (fasting, TPN)
Increased Hb breakdown
-Haemolytic disorders (spherocytosis, sickle cell or malaria)
What are the 3 gallstone compositions
Cholesterol (often solitary, smooth, large)
Mixed (predominantly cholesterol, multiple, generations range of colours and shapes)
Pigment (bile pigments, multiple, small, irregular and fragile)
What is cholelithiasis
Stones in the gallbladder
What is choledocholithiasis
Stones in the bile duct
What is cholestasis
reduction or stoppage of bile flow
What is biliary colic
when cystic duct becomes impacted by gallstone
Pain of biliary colic
Sudden, sharp, stabbing, RUQ- epigastric pain. Typically radiates to right shoulder and lasts <6h
Associations of pain of biliary colic
Eating (esp fatty foods)
Associated N&V
Examination findings of biliary colic
Apyrexial. typically unremarkable
Investigations nad management of biliary colic
Stones on USS
-Ultrasound, outpatient cholecystectomy
IS jaundice present in biliary colic
No as bile can still drain via common bile duct
What is cholecystitis
Stone impacted in neck go gallbladder or cystic duct results in super concentrate, irritant. Bile can get infected by ascending gut bacteria (klebsiella, e.coli)
What bacteria can cause infections in cholecystitis
Klebsiella
E. coli
Pain and associations in cholecystitis
Pain- constant RUQ- epigastric pain which persists. Main radiate to right shoulder
Associations- may babe N&V. Likely to have fever and or lethargy
Examination findings in cholecystitis
Tender RUQ with possible guarding.
Murphy’s sign - Whilst applying pressure in RUQ ask patient to inspire deeply. Positive when there is a halt in inspiration due to pain. Similar manoeuvre in LUQ should not elicit discomfort
Investigation findings in cholecystitis
Raised inflammation markers
Mildly raised AST/ALT/ALP
May have slightly raised bilirubin
USS shows enlarged gall bladder with stones and thickened walls
Management of cholecystitis
Analgesia Nil by mouth IV fluids Cholecystectomy within one week Antiemetics if required Antibiotics (cef + met)
Are patients jaundiced in cholecystitis
No
What is cholangitis
Biliary outflow obstruction and ascending infection
What pain and associations are there in cholangitis
RUQ, persistent, colicy in nature?
Jaundiced, typically unwell and pyrexial with rigors
-May also have pruritus, pale stool and dark urine. Often causes sepsis
Examination findings in cholangitis
Tender RUQ with possible guarding. Pyrexial. Jaundiced.
Investigation finding in cholangitis
raised WCC, blood cultures
Raised bilirubin
Raised ALP/GGT> AST/ALT
USS shows dilated bile ducts and/or gall bladder stones and/or ductal stones
Management of cholangitis
Analgesia,
Nil by mouth
IV antibiotics
ERCP
What blood tests to do if suspect gallbladder disease
FBC, U&E, LFT, CRRP, amylase
VBG+ blood cultures –> cholangitis
What imaging options to use if ultrasound is inconclusive
CT scan
MRCP - detailed visualisation of biliary tree
ERCP- Contrast passed into biliary tree so you. can see. Whilst there, can unblock common bile duct. Gold standard for cholangitis
What is a T tube and why is it used
Used if ERCP fails in cholangitis
- Prevents common bile duct blockage due to swelling
- Prevents bile leakage into Abdo cavity
- Not reco. ended for routine use
Wn a patient with painless jaundice and enlarged gallbladder what Is the likely cause
Obstructing malignancy until proven otherwise
What is gallstone ileus
Inflammation of the gallbladder can cause a fistula between the gallbladder wall and the duodenum allowing gallstones to pass into the small bowel directly. if a stone impacts a terminal ileum this results in small bowel obstruction.
