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gallbladder disease Flashcards

1
Q

What is the pathophysiology of cholelithiasis (gallstones)?

A

It involves an imbalance between components of bile (supersaturation) and biliary stasis.

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2
Q

What are the classic “5 F” risk factors for gallstones?

A

Female, Fat, Fertile, Forty, fair skin.

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3
Q

Name other risk factors for gallstones apart from the 5Fs.

A

Obesity, rapid weight loss, hyperlipidemia, hemolytic anemias (e.g., SCD), Crohn’s disease, and terminal ileum resection.

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4
Q

What is the most common type of gallstone?

A

Cholesterol stones (80%), which are non-pigmented.

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5
Q

When do cholesterol stones form?

A

With bile supersaturation with cholesterol, especially after rich fatty meals in obese individuals.

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6
Q

What percentage of gallstones are bilirubin stones, and when do they occur?

A

About 15%; they occur in patients with hemolysis like SCD.

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7
Q

What are the types of bilirubin stones and their appearances?

A

• Calcium bilirubinate (black stones)
• Infected bilirubin stones (brown stones)

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8
Q

What type of stones are found in Crohn’s disease patients?

A

Calcium oxalate stones.

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9
Q

What is the clinical presentation of asymptomatic gallstones?

A

Most are incidentally discovered on imaging; risk of symptoms is 1% per year.

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10
Q

Describe the features of symptomatic gallstones (biliary colic).

A

• RUQ colicky pain lasting 1–3 hours
• Steady pain with increased severity
• Triggered by fatty meals
• May radiate to the right shoulder or scapula (Boas sign)
• Can be associated with nausea and vomiting
• Persistent background pain

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11
Q

What are signs of complicated gallstones?

A

• Choledocholithiasis (obstructive jaundice)
• Acute cholecystitis
• Ascending cholangitis
• Gallstone pancreatitis
• Mucocele
• Empyema
• Mirizzi syndrome
• Gallstone ileus

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12
Q

What lab tests are done in suspected biliary colic or acute abdomen?

A

• CBC: to assess WBCs (infection vs inflammation)
• LFTs: rule out hepatitis or biliary obstruction
• Amylase + Lipase: rule out acute pancreatitis
• RFTs: rule out renal causes
• Urinalysis: rule out UTI or stones

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13
Q

What imaging studies are used for gallbladder evaluation?

A

• Gallbladder ultrasound (gold standard):
• Patient must be fasting
• Checks for gallstones and CBD dilation (suggests distal obstruction)
• CXR: to rule out pneumonia (can mimic upper abdominal pain)

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14
Q

What is the treatment for asymptomatic gallstones?

A

No treatment required.

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15
Q

What is the treatment for mild symptomatic gallstones?

A

Analgesia and lifestyle changes (e.g., low-fat diet).

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16
Q

How are severe symptoms or complications managed?

A

• Analgesia (morphine + antiemetic + buscopan)
• IV broad-spectrum antibiotics
• Laparoscopic cholecystectomy

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17
Q

What drug may help dissolve gallstones in non-surgical cases?

A

Ursodeoxycholic acid

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18
Q

When can a patient with biliary colic be discharged?

A

After improvement in vitals, appetite, and if tolerating oral intake

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19
Q

What are the indications for cholecystectomy?

A

• Severely symptomatic gallstones
• Asymptomatic patients with: SCD, diabetes, immunocompromised, large stones, porcelain gallbladder
• Complicated gallstones

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20
Q

What are key safety considerations during cholecystectomy?

A

• Gallbladder lies on liver’s visceral surface
• Cystic artery and duct are exposed
• Calot’s (Ludwig’s) triangle: critical to identify artery and duct safely

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21
Q

What are the laparoscopic port (trocar) sites for cholecystectomy?

A
  1. Infraumbilical (camera)
  2. RUQ (assistant)
  3. LUQ (surgeon)
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22
Q

What is the surgical incision site for open cholecystectomy?

A

Kocher incision (right hypochondrium)

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23
Q

What are the steps of laparoscopic cholecystectomy?

A
  1. Achieve critical view of safety
    1. Free and ligate the cystic duct and artery
    2. Free gallbladder from liver bed
    3. Remove through umbilical port
    4. Send gallbladder for histopathology
    5. Be cautious of injuring the right hepatic artery
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24
Q

What are general laparoscopic complications of cholecystectomy

A

Introduction injury, air embolism, and low blood pressure.

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25
What are specific complications of cholecystectomy?
• Damage to the right hepatic artery or common bile duct (CBD) • Retained stones entering CBD → post-op RUQ pain & obstructive jaundice • Bile leakage & peritonitis
26
What is choledocholithiasis?
Presence of a gallstone in the common bile duct (CBD) — a complication of gallstones.
27
What are the clinical features of choledocholithiasis?
• Biliary colic symptoms • Cholestasis signs: jaundice, pale stools, dark urine, pruritus, and bleeding tendency • Complications: pancreatitis, cholangitis
28
What lab findings suggest cholestasis in choledocholithiasis?
Elevated ALK-P, GGT, and conjugated bilirubin
29
What imaging and procedures are used for diagnosis?
• Ultrasound: assess proximal CBD dilation • ERCP: both diagnostic and therapeutic
30
How is choledocholithiasis managed?
1. ERCP + sphincterotomy + basket retrieval 2. If unsuccessful: CBD exploration, stone removal, T-tube placement 3. Interval cholecystectomy after LFTs normalize
31
What causes acute calculous cholecystitis?
Inflammation of the gallbladder wall due to cystic duct obstruction by a stone (not due to infection initially).
32
What are the key symptoms of acute cholecystitis?
• Steady, severe RUQ pain lasting >3–6 hours • Pain may radiate to right shoulder/scapula • Triggered by fatty meals • Associated with nausea and vomiting
33
What are signs of biliary tract obstruction?
• Jaundice • Pruritus (due to bile salts) • Clay-colored stools • Dark urine
34
What are key examination findings in acute cholecystitis?
• RUQ tenderness with or without rebound • Murphy’s sign (inspiratory arrest on RUQ palpation) • Palpable tender gallbladder in 33% of patients • Low-grade fever
35
What are the complications of acute cholecystitis?
• Same as gallstone complications • Mucocele or empyema of the gallbladder • Perforation and bile peritonitis • Cholecystoenteric fistula → can cause gallstone ileus • Risk of gallbladder cancer
36
How does a cholecystoenteric fistula form?
The omentum tries to contain infection by covering the gallbladder, bringing it into contact with the intestine and allowing a fistula to form.
37
What lab tests are important in evaluating acute cholecystitis?
• CBC: leukocytosis • LFTs: assess liver function • Amylase & lipase: rule out pancreatitis • Urinalysis: rule out pyelonephritis • Others: RFTs, electrolytes
38
What imaging modalities are used in diagnosis?
• CXR: rule out lung causes, look for air under diaphragm • RUQ ultrasound (required for diagnosis): • Gallbladder wall thickening >4mm • Pericholecystic fluid • Stone in cystic duct • Sonographic Murphy’s sign • CT scan: better at detecting complications (e.g., perforation, abscess) • HIDA scan: shows non-filling gallbladder if US is inconclusive
39
What are the steps in conservative management of Acute Cholecystitis?
1. NPO + IV fluids 2. IV broad-spectrum antibiotics (3rd-gen cephalosporins + metronidazole) 3. IV analgesia (morphine + buscopan + antiemetic) 4. Correct electrolyte abnormalities
40
What is the management if the patient presents within 48–72 hours?
• Urgent laparoscopic cholecystectomy • Or open cholecystectomy (if complicated)
41
What is the approach if the patient presents after >72 hours?
• Continue conservative management • Perform interval cholecystectomy after 6+ weeks • If condition worsens: proceed with surgery or percutaneous cholecystostomy
42
What is acalculous cholecystitis?
Inflammation of the gallbladder without gallstones (rare).
43
What are the risk factors for acalculous cholecystitis?
• ICU patients (NPO, on TPN) • Postoperative or hospitalized patients • Dehydration • Biliary stasis or hypoperfusion
44
What are the clinical features and investigations in acalculous cholecystitis?
Same as acute cholecystitis, but no stones seen on imaging; biliary sludge may be present.
45
What is the treatment for acalculous cholecystitis?
Urgent cholecystectomy
46
What is gallstone ileus?
Small bowel obstruction at the ileocecal valve caused by a large gallstone (>2 cm) that entered via a cholecystoenteric fistula.
47
What are the clinical features of gallstone ileus?
• SBO symptoms: abdominal pain, distension, bilious vomiting, constipation • Signs: distension, tenderness, hyperactive bowel sounds
48
What are key imaging findings in gallstone ileus?
• Erect AXR: step-ladder air-fluid levels, pneumobilia, ileocecal valve obstruction • Supine AXR: centrally collected air • CT abdomen: pneumobilia, fistula, and gallstone
49
How is gallstone ileus managed?
• Same as SBO • Exploratory laparotomy: • Enterotomy and stone removal • If stable: cholecystectomy + fistulectomy • If unstable: interval cholecystectomy
50
What is acute (ascending) cholangitis?
A bacterial infection of the biliary tract above an obstruction in the CBD, due to biliary stasis.
51
Why is acute cholangitis considered life-threatening?
It has a high mortality (up to 50%) if not treated emergently.
52
What are the causes of cholangitis?
• Intraluminal: choledocholithiasis (most common), biliary stents • Intramural: strictures (e.g. post-ERCP), cancer, choledochal cyst • Extraluminal: Mirizzi syndrome, pancreatic head cancer, pseudocyst
53
What are the common causative organisms in cholangitis?
• E. coli (most common) • Others: Klebsiella, Proteus, Enterobacter, Pseudomonas, Enterococcus
54
What are the key symptoms of acute cholangitis?
• RUQ pain • Nausea and vomiting • High-grade fever with chills • Cholestasis signs: jaundice, dark urine, pale stools, pruritus
55
What are the key signs in severe cases of cholangitis?
• Toxic appearance: tachycardia, high fever, hypotension, dehydration • Jaundice • Suggests sepsis or progression to Reynolds’ pentad
56
What is the most serious complication of acute cholangitis?
Hepatic abscess
57
What is the first priority in a patient with suspected cholangitis?
Stabilization — ABCs, IV fluids, NPO, and labs
58
What laboratory tests are done?
• CBC: leukocytosis • CRP & ESR: elevated • LFTs: cholestatic pattern (↑ ALP, GGT, direct bilirubin) • Electrolytes panel: assess imbalances • Urinalysis: rule out UTI • Amylase & lipase: rule out pancreatitis • Blood cultures: usually positive (septicemia)
59
What is the best initial imaging study?
• RUQ ultrasound • May show dilated CBD, multiple stones • Helps rule out extrinsic causes
60
What is the modality of choice for diagnosis and treatment?
• ERCP (Endoscopic Retrograde Cholangiopancreatography) • Diagnostic + therapeutic • If Charcot’s triad is present, proceed directly • May reveal pus at ampulla
61
What is the immediate management approach?
• ABCs, fluid resuscitation, NPO • IV antibiotics: cephalosporins + metronidazole • IV analgesia
62
What is the definitive treatment for cholangitis?
• ERCP: sphincterotomy, stone extraction, pus drainage
63
What are the next steps if ERCP fails?
1. PTC (Percutaneous transhepatic cholangiography) for drainage 2. If PTC fails → open surgery with CBD exploration + T-tube insertion
64
What surgical step must follow after cholangitis resolution?
Interval cholecystectomy (to prevent recurrence)
65
What is Charcot’s triad?
1. RUQ pain 2. Fever and chills 3. Jaundice
66
What is Reynolds’ pentad (triad + 2)?
4. Altered mental status 5. Hypotension → Indicates severe, septic cholangitis

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