Gallbladder Disease**** Flashcards
What makes up 80% of gallstones?
What else can the gallstones be made of? - 2
How often do they tend to become symptomatic?
What does the clinical presentation depend on?
Cholesterol
Bile pigments (from broken down Hb) or a mix (also containing calcium salts)
Once a yr
The location
Anatomical locations:
Cholelithiasis:
- Define?
- How can it typically present in terms of disease? - 3
- What is mirizzi’s syndrome?
Simply gallstones in the gallbladder
Acute cholecystitis
Chronic cholecystitis
Biliary colic
Stones in the gallbladder or cystic duct cause obstructive jaundice via extrinsic compression of the CBD - RARE
Anatomical locations:
Choledocholithiasis:
- Define?
- How can it typically present in terms of disease? - 3
Gallstone ileus:
- Define?
Gallstones in the CBD - d in duct and d in chole……
Obstructive jaundice
Acute cholangitis
Acute pancreatitis
Gallstones obstructing small bowel
Risk factors:
5F’s
FOOD mneumonic - define
Fat or rapid weight loss Female Forty (age) - due to premenopausal oestrogen increases risk Fair - white ethnicity Fertile - multiparity --- FH Oral contraception Older age DM
Biliary colic:
Define it
Why do you get pain?
Where is the obstruction?
Biliary obstruction without infection
Gallbladder contracts against the obstruction
Stone impaction in the gallbladder neck or cystic duct.
Biliary colic - S+S:
The pain - can be very severe:
- sites - 2
- time
- radiation
- what makes it worse
What other symptoms might you get? - 1
How long does it take for it to resolve?
What indicates there is not infection?
RUQ or epigastric pain (not colicky)
Continuous
Back (below the right scapula)
After a fatty meal
N&V - NO JAUNDICE
< 6 hrs
No fever, peritonism or raised WBC
Biliary colic - Investigations:
Initial imaging and one blood test?
When should an MRCP be considered? - 2
Why can you not use an AXR?
Abdo USS and LFT’s
Duct dilatation on USS and/or abnormal LFT’s
Most gallstones are radiolucent on XR unlike renal stones so you wouldn’t see them.
Biliary colic - Management:
What can be given for pain?
Any advice?
What surgery can be done?
Biliary colic - Management:
If they are CBD stones, how can they be removed? - 2
How should they be advised after surgery?
Analgesia - parenteral opioid or PR diclofenac
Triggering foods and drinks i.e. low fat diet
Laparoscopic cholecystectomy
ERCP
Clearance during cholecystectomy
Consume normal diet including previous triggering foods
Acute cholecystitis:
What is it?
Where is the stone impacted? - 2
What may it initially look like?
What may it come after?
Acute gallbladder inflammation
Cystic duct
Gallbladder neck
Biliary colic
May come as a complication of biliary colic (>6 hrs)
Acute cholecystitis:
The pain - can be very severe:
- sites - 2
- time
- radiation
What other GI symptom may they have?
Boas sign is a sign of AC. What is it?
What is the difference between AC and BC? - 2
RUQ or epigastric pain (not colicky)
Continuous
Back (below the right scapula)
Vomiting
Extreme tenderness in the area of back pain below the scapula
Fever and local peritonism
The patient usually lying still instead of the writhing of biliary colic
Acute cholecystitis:
Murphy’s sign is a sign of AC. How it elicited? - 3
What must be ensured to make sure it is a positive test?
With 2 fingers pressed on RUQ
There is pain on inspiration
Patient stops breathing
If negative on LUQ
Acute cholecystitis:
Phlegmon and the gallbladder may be palpable in the RUQ. What is phlegmon?
Why could jaundice happen in 10% of patients?
What is the name for an infection of the CBD?
Inflamed omentum and bowel around the gallbladder
Due to compression, inflammation or stone impaction in the CBD - Mizzi’s syndrome - rare
Cholangitis
Acute cholecystitis - Investigations:
- Bloods and why?
Imaging
FBC - raised WBC
Inflammatory markers - Raised CRP
LFT - raised liver enzymes (e.g. alkaline phosphate, BR and GGT)
Acute cholecystitis - Investigations:
Best imaging to use is the abdo USS!!!!
How long should the patient be NBM and why?
What may you find on USS? - 1 - What if it is chronic? - 1
How may you elicit Murphy’s sign?
What may suggest there are stones in the CBD?
Abdo USS
4 hrs - will show distended gallbladder
Thick-walled gallbladder
It will be shrunken
Pain when compressing GB with the probe
Dilated CBD (6mm)
Acute cholecystitis - Investigations:
What type of imaging should be done if the USS shows dilated CBD and obstructive LFT’s are failing to improve?
What can be done if the previous is inconclusive?
MRCP - magnetic resonance cholangiopancreatography
Provides detailed images of your liver, gallbladder, bile ducts, pancreas and pancreatic duct.
An endoscopic US - EUS
A special endoscope uses high-frequency sound waves to produce detailed images of the lining and walls of your digestive tract and chest, nearby organs such as the pancreas and liver, and lymph nodes.
Acute cholecystitis - Investigations:
For cystic duct obstruction, HIDA scan can be done. What does it involve?
What other scan be done if there are complications?
Also called cholescintigraphy or hepatobiliary scintigraphy, is an imaging test used to view the liver, gallbladder, bile ducts, and small intestine.
The scan involves injecting a radioactive tracer into a person’s vein.
CT scan
Acute cholecystitis - Management:
Non-operative - 2
Because recurrences are common, what is offered to patients?
What is done if there are CBD stones? - 2
What is a percutaneous cholecystotomy tube (PCT) and why is it used? - 2
Supportive Rx - fluids and analgesia
ABs IV
Laparoscopic cholecystectomy
ERCP pre-op or intra-operatively bile duct clearance
For drainage for the urgent treatment of perforation
If the patient unfit for surgery
Acute cholecystitis - 3 complications:
Infarction - what is this called and what may it lead to?
Gallbladder empyema - what is another name for it? what is it?
Chronic cholecystitis - what could this lead to?
Gangrenous cholecystitis leading to perforation
Leads to peritonitis and high mortality
Gallbladder empyema (aka suppurative cholecystitis) Gallbladder lumen is filled and distended by purulent material (pus).
Repeated episodes leads to fibrosed and shrunken gallbladder
What should be done if there is worsening LFT’s with obstructive jaundice with CBD stones?
ERCP with sphincterotomy with biliary trawl (cutting open sphincter allowing easy passage of bile)
Chronic cholecystitis:
What makes it chronic?
Other S+S?
Rx?
Chronic inflammation
Abdominal discomfort DIstention Nausea Flatulence Fat intolerance
Same as acute - just not as quickly
Acute cholangitis:
What is it?
What imaging can cause it?
What else may cause it?
What is it also known as?
What is the main difference between acute cholangitis vs acute cholecystitis?
Infection of the bile duct
ERCP
Biliary malignancy
Ascending cholangitis
You do not get tenderness in acute cholangitis as the biliary ducts are not close enough to the skin to press on them
Acute cholangitis - clinical features:
What are the 3 parts of Charcot’s triad (all 3 present in 60% of cases)
RUQ pain
Obstructive jaundice
Rigors
Acute cholangitis - Investigations:
Bloods and why? - 2
Imaging - 2
FBC - raised WBC
LFTs - Raised BR, alk phosphate and GGT
USS
MRCP
MRCP vs ERCP
A major feature of MRCP is that it is not a therapeutic procedure, while in contrast ERCP is used for both diagnosis and treatment. MRCP also does not have the small but definite morbidity and mortality associated with ERCP.
Acute cholangitis - Management:
Initial for infection
What is done once stable
What are 2 ways CBD stones can be dealt with if they cannot be retrieved? - 2
What is the last resort?
IV and fluids
ERCP once stable
Sphincterotomy and stone clearance
Stenting
Cholecystectomy and CBD clearance
Gallstone ileus:
What is it?
CLUE - stone that pass through the sphincter of Odi unlikely to….
Where does it happen?
What would you see on AXR? - 2
A large gallstone that erodes through the gallbladder into the duodenum causing small bowel obstruction
The narrowest point in small bowel - 2 feet proximal to the ileocecal valve
Dilated loops of bowel and air in the biliary tree (entered through the fistula
Laparoscopic cholecystectomy:
Where is the port put in for gallbladder removal?
Why is it better than open?
Umbilicus
Shorter stay
Faster recovery
No difference in mortality or complications though
Laparoscopic cholecystectomy:
General complications of abdominal laparoscopic surgery:
- why might you get cardiorespiratory strain?
- why does it need longer training and more equipment?
Surgical pneumoperitoneum which reduces venous return - may be harder for patients with heart or lung disease
It is more difficult compared to open - you might also need to convert to open if it is not possible
Laparoscopic cholecystectomy:
Specific complications of laparoscopic surgery:
- Why are people with bleeding disorders contraindicated?
- Injury of what? - 2
- What may be missed?
- Where may an abscess form?
It is harder to deal with intraoperative bleeding (e.g cystic or hepatic artery)
CBD injury
Bowel injury
Missed CBD stones
Sub-hepatic
