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Y4 - Surgery - General > Gallstone Disease > Flashcards

Gallstone Disease Flashcards

1
Q

ESSENCE

A

Small stones that form within gallbladder, from concentrated bile in the bile duct

Most are made of cholesterol

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2
Q

What complications can they lead to

A
  • Acute cholecystitis
  • Acute cholangitis
  • Pancreatitis
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3
Q

ANATOMY

Describe the relevent anatomy

A
  • Right and left hepatic duct leave liver and join together to form common hepatic duct
  • Cystic duct from gallbladder joints the common hepatic duct halfway along
  • Pancreatic duct joins common hepatic duct further along, when they join it becomes ampulla of Vater which opens onto duodenum
  • Sphincter of Oddi is ring of muscle surround ampulla of Vater that controls the flow of bile and pancreatic secretions into duodenum
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4
Q

ANATOMY

What is muscle around ampulla of Vater called

A

Sphincter of Oddi

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5
Q

AETIOLOGY

Risk factors

A
  • Remember 4Fs
    • Fat
    • Fair
    • Female
    • Forty
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6
Q

Formation of gallstones is called

A

Cholelithiasis

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7
Q

AETIOLOGY

Pathophysiology

A
  • Cholesterol cholelithiasis occurs due to 3 principle defects
    • Bile supersaturated with cholesterol
    • Accelerated nucleation
    • Gallbladder hypomotility retaining abnormal bile
  • Symptoms result when stones block cystic and/or bile ducts
  • If blocks bile duct causing obstruction causes acute cholangitis
  • If obstructs ampulla causes acute bilary pancreatitis
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8
Q

CLINICAL FEATURES

Presentation

A
  • Asymptomatic 80%
  • Bilary colic if stones blocking drainage of gallbladder
    • Severe, colicky epigastric or right upper quadrant pain
    • Often triggered by meals
    • Lasting 30min-8 hours
    • May be associated with nausea and vomiting
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9
Q

Why are patients with gallstones advised to avoid fatty food

A
  • Fat entering digestive tract causes secretion of cholecystokinin (CCK) from duodenum
  • This causes contractions of gallbladder, leading to bilary colid
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10
Q

INVESTIGATIONS

First choice

A
  • Abdominal US - see stones
  • Magnetic resonance cholangio-pancreatography (MRCP) if US doesnt show stones
  • Possible endoscopic retrograde cholangio-pancreatography (ERCP)
  • Maybe CT to look for differentials
  • LFTs - normal if uncomplicated, deranged if complicated
  • Serum lipase and amylase - pancreatitis
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11
Q

What are US findings

A
  • Can identify
    • Gallstones in gallbladder
    • Gallstones in ducts
    • Bile duct dilation (normaly <6mm)
    • Acute cholecystitis
    • Pancreas and pancreatic duct
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12
Q

Indication for ERCP

A

Clear stones in bile duct

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13
Q

Key compications of ERCP

A
  • Excessive bleeding
  • Cholangitis (infection in bile ducts)
  • Pancreatitis
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14
Q

What do LFTs look at

A
  • Bilirubin
  • Alkaline phosphatase (ALP)
  • Aminotransferases
    • Alanine aminotransferase (ALT) and asparate aminotransferase (AST)
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15
Q

How are LFTs changed

A
  • Raised bilirubin indicates obstruction to flow within biliary system, maybe obstruction due to gallstones
  • Raised ALP
  • Both raised but ALP raised higher - obstructive picture
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16
Q

Signs of raised bilirubin

A
  • Jaundice
  • Pale stools
  • Dark urine
17
Q

How does bilirubin normally drain

A

From liver, through bile ducts and into intestines

So if this is obstructed (by stones or external mass like tumour) bilirubin is raised

18
Q

What is alkaline phosphatase (ALP)

A
  • Enzyme originating in liver, biliary system and bone
  • Abnormal result indicates liver or bone problem
  • Often raised in pregnancy due to production by placenta
19
Q

What are aminotransferases

A
  • Alanine aminotransferase (ALT) and asparate aminotransferase (AST) are enzymes produced in liver
  • Markers of hepatocellular injury (damage to liver cells)
20
Q
A
21
Q

What can be determined by changes in ALP compared to ALT/AST

A

Obstructive picture - higher rise in ALP than ALT and AST

Hepatic picture - higher rise in ALT and AST than ALP

22
Q

MANAGEMENT

General principles

A
  • Asymptomatic patients may be treated conservatively with no intervention
  • With symptoms or complications are treated by cholecystectomy
23
Q

What is cholecystectomy

A
  • Surgical removal of gallbladder
    • Can be laparoscopic or open using Kocher incision (right subcostal incision)
24
Q

Complications of cholecystectomy

A
  • Bleeding, infection, pain and scars
  • Damage to the bile duct including leakage and strictures
  • Stones left in the bile duct
  • Damage to the bowel, blood vessels or other organs
  • Anaesthetic risks
  • Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
  • Post-cholecystectomy syndrome
25
Q

Presentation of post-cholecystectomy syndrome

A
  • Symptoms often improve with time
    • Diarrhoea
    • Indigestion
    • Epigastric or right upper quadrant pain and discomfort
    • Nausea
    • Intolerance of fatty foods
    • Flatulence

Y4 - Surgery - General (43 decks)

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