Gallbladder problems

Question 1

Why does biliary colic occur

Answer 1

Gallbladder neck becomes impacted by a gallstone. Contraction of the gallbladder against occluded neck will cause pain
there is no inflammatory response

Question 2

What type of pain is associated with biliary colic

Answer 2

Sudden, dull and achey
Comes in waves
in RUQ

Question 3

What makes biliary colic worse

Answer 3

Consumption of fatty foods

causes secretion of cholecystikinin and this causes the gallbladder to contract

Question 4

What are the risk factors for developing gallstones

Answer 4

5Fs
Female 
Fat 
Fertile
Forty 
Family hx

Other recognised risk factors

• pregnancy
• COCP - oestrogen causes more cholestrol to be secreted into the bile
• malabsorption - crohns
• haemolytic anaemia

Question 5

What are the clinical features of acute cholcystitis

Answer 5

Tender in the RUQ
Positive Murphys sign
Pain more constant and persistent despite pain relief
Signs of inflammation - increased temp, increased WCC
Fever

Question 6

What are the differentials for RUQ

Answer 6

GORD
Acute pancreatitis
Peptic ulcer disease
inflammatory bowel disease

Question 7

How would you investigate RUQ

Answer 7

Bedside obs
Urine dip - rule out renal or tubo-ovarian pathology
Pregnancy test
Bloods
- FBC and CRP - inflammation
- U+Es - assess for dehydration
- LFTs - in biliary colic and acute cholecystitis just raised ALP
with cholangitis there will be raised ALP, GGT an raised bilirubin
- Amylase
- Blood cultures in suspected cholangitis

Imaging
- trans-abdominal USS
*presence of gallstones
*gallbladder wall thickening
*bile duct dilatation
MRCP - gold standard for biliary colic and cholecystitis, can show potential defects in biliary tree
ERCP - gold standard for cholangitis - both diagnostic and therapeutic

Question 8

What is the initial management for biliary colic

Answer 8

IV Access - bloods taken
If poor U+Es - fluids
Analgesia - NSAIDs and PRN opiods
Antiemetic

Lifestyle advice 
- lose weight 
- low fat diet 
- increase exercise 
Provided with PRN analgesia at discharge

Question 9

What is the definitive treatment for Biliary colic

Answer 9

high chance of symptom recurrence or development of complications
- elective cholecystectomy - ideally offering within 6 weeks of presentation

Question 10

What is the initial management for acute cholecystitis

Answer 10

IV access 
bloods
Fluid resuscitation 
analgesia and antiemetic
IV abx - co-amoxiclav +/- metrondiazole 
NG tube if pt vomiting 
Pt made NBM - ultrasound more sensitive if absence of bowel gas

Question 11

What is the definitive management in acute cholecystitis

Answer 11

Laparoscopic cholecystectomy indicated within 1 week

should ideally be done within 72hrs of presentation

Question 12

What is the pathophysiology of ascending cholangitis

Answer 12

biliary outflow obstruction causes stasis of fluid and increased elevated intraluminal pressure which allows bacterial colonisation of the biliary tree to become pathological

Question 13

Which organisms commonly cause cholangitis

Answer 13

E.coli
Klebsiella
Enterococcus

Question 14

What are the causes of cholangitis

Answer 14

Any condition that causes obstruction of the biliary tree

• gallstones
• ERCP
• cholangiocarcinoma

Rarer causes include

• pancreatitis
• primary sclerosing cholangitis
• ischaemic cholangiopathy
• parasitic infections

Question 15

How does cholangitis present

Answer 15

RUQ pain
Jaundice (bilirubin >50umol/L)
Fever
(charcots triad)

On examination

• rigors
• pyrexia
• RUQ tenderness
• confusion
• hypotension
• tachycardia

PmHx - may include previous gallstones, recent bilary intrumentation or previous cholangitis

Question 16

What is the initial management for cholangitis

Answer 16

Iv Access - bloods taken
Fluid resuscitation
Blood cultures taken
IV Broad spectrum abx - co amoxiclav and metronidazole

Question 17

What is the definitive management for cholangitis

Answer 17

Endoscopic biliary decompression - removing the cause of the blocked bile duct
ERCP - should clear any obstruction
If too sick to tolerate ERCP then percutaneous cholangiograhy is second line
May require cholecystectomy if gallstones were underlying cause

Question 18

What are the complications of ERCP

Answer 18

Repeated cholangitis
Pancreatitis
Bleeding
Perforation

Question 19

What is a gallbladder empyema

Answer 19

Gallbladder becomes infected and an abscess forms within it
Patients are typically septic
Diagnoses via US or CT
treated via a lap chole

Question 20

What are some of the complications of gallstones

Answer 20

Gallstone empyema
Fistula between gallbladder and duodenum
Gallbladder ileus - stone causes obstruction at terminal ileum
Bouverets syndrome - stone impacts to cause duodenum obstruction
Acute pancreatitis
obstructive jaundice