Gallstone Disease Flashcards
What causes gall stones?
Bile stays in the gall bladder too long. Anything that keeps the bile in the gallbladder for longer will facilitate stone formation. Gallbladder dysmotility is exactly that—bile staying in the gallbladder too long. This occurs due to
—-rapid weight loss,
—-prolonged fasting, and
—-biliary dyskinesia.
You should know three stone types: cholesterol (green), pigmented (black), and brown
What are the different types of gall stones?
_________________ gallstones are the most common type and are green in color.
Cholesterol
What are the risk factors for cholesterol gall stones?
Risk factors are the “five F’s:” female, fertile (pregnant), fat (obesity), forty (middle age most common), and fNative American (the F is silent).
What is the main contributing factor to pigemneted gallstones?
Hemolysis!
Pigmented stones of the gallbladder are black, made of mostly unconjugated bilirubin,and caused by hemolysis. Pigmented gallstones can occur in children with hereditary causes of hemolytic anemia. Cholesterol stones do not form in kids.
Where do brown stones come from?
Brown stones are not gallbladder stones but rather primary stones of the biliary tree. They are caused by bacterial infection of the biliary tree, resulting in bacterial β-glucuronidase deconjugating bilirubin. They do not sit in the gallbladder with other stones, so their surface is smooth, whereas gallstones are more jagged.
Where are the major places you can get a gallstone stuck?
in the gallbladder, the cystic duct, or the common bile duct
How does the work up for gallstones in the gallbladder differ from those stuck in the common bile duct?
Gallstones in the gallbladder primarily present with right upper quadrant (RUQ)pain and a tender, inflamed gallbladder.This should be worked up with a RUQ ultrasound, and it is corrected with cholecystectomy. Gallstones in the common bile duct also present with pain, but because the common bile duct is occluded, there will be jaundice and elevated L F Ts (and lipase, if the pancreas is involved). The work-up begins with a RUQ ultrasound but will need an MRCP to evaluate, ERCP to treat, and subsequent follow-up cholecystectomy.
is an obstructing gallstone without infection or superimposed pancreatitis, as the obstruction is proximal to the hepatopancreatic ampulla.
choledocolithasis
What is an ERCP?
An EGD that cannulates the hepatopancreatic sphincter (aka the sphincter of Oddi); uses a wire to infuse contrast dye, cut the sphincter (if necessary), and slip a retrieval balloon behind the stone; inflates the balloon; and yanks the stone out through the hepatopancreatic ampulla and sphincter.
When is a HIDA scan warranted?
HIDA scans can help provide definitive dx for biliary dyskinesia (failure of the gallbladder to empty fully on HIDA) and cholecystitis (failure of the gallbladder to fill on HIDA) are biliary pathologies you studied in this lesson, and both are diagnosed definitively by HIDA scan.
The question is whether she simply has symptomatic cholelithiasis or she has acute cholecystitis. If the ultrasound does not reveal what you need it to, the best way to determine is via HIDA scan, which is a nuclear tracer. If the gallbladder does not light up with tracer, there is an obstruction preventing the tracer from entering the gallbladder, an obstruction of the cystic duct. That is the same thing as saying an obstruction preventing bile from the gallbladder through the cystic duct. And thus, the diagnosis of acute cholecystitis is made. This is important because untreated cholecystitis will eventually lead to necrosis and perforation, whereas symptomatic cholelithiasis can be managed electively. When the diagnosis is certain, but the ultrasound doesn’t strictly agree, get a HIDA nuclear scan.
Reynolds pentad
RUQ, jaundice, fever, AMS, and hypotension
RUQ, jaundice, and fever
charcot’s triad
What is concerning with reynolds pentad?
Septic shock , seen in ascending cholangitis
How do we address ascending cholangitis?
ERCP
What is charcot’s triad concerning for?
Ascending cholangitis
obstructive pattern on LFTs, sepsis by vitals and CBC and charcot’s triad
ascending cholangitis
What kind of orgnaisms cause ascending cholangitis?
The organisms that cause ascending cholangitis ascend from the gut. It is typically associated with gram-negative organisms and anaerobes. The goal is to use targeted therapy to ensure coverage of all likely organisms but not to give too much coverage for unnecessary organisms. In this case, ampicillin + sulbactam covers the gram-negatives, while metronidazole covers the anaerobes. Thus, the right answer is ampicillin-sulbactam and metronidazole.
Fat female w/A right upper quadrant ultrasound shows biliary sludging and gallstones without pericholecystic fluid. The gallbladder wall is mildly thickened.
What is the best next step in the management of this patient?
HIDA SCAN
The question is whether she simply has symptomatic cholelithiasis or she has acute cholecystitis. If the ultrasound does not reveal what you need it to, the best way to determine is via HIDA scan, which is a nuclear tracer.
What is circled in green on this liver US?
Pericholecystic fluid- note the mixed echogenicity
Where would the obstructing stone be on this US? Can we see it?
Although there are stones to the right (note the hypoechoic shadow marked by the red arrow), the obstructing stone would be where the green dot is and we often dont see it on US
Gallstones in the common bile duct can cause what ?
Gallstones in the common bile duct can be choledocholithiasis, ascending cholangitis, or gallstone pancreatitis.
When may you see jaundice in a gallstone based problem?
Gallstones in the common bile duct also present with pain, but because the common bile duct is occluded, there will be jaundice and elevated LFTs (and lipase if the pancreas is involved).
Why do you see jaundice in choledocolethiasis and not cholecystitis?
Blockage of the common bile duct in choledocolethiasis!
Give a breif overview of the different gall stone problems in the gallbladder
What do gall stones look like on imaging?
breif overview of gallstone problems in the common bile duct
What symptoms should you be aware of for gallstone pancreatitis?
anorexia, epigastric pain, nausea, vomiting—and the labs reflect pancreatitis—elevated lipase and amylase. Ultrasound will show common bile duct dilation. MRCP confirms that the stone is there. ERCP is performed to retrieve the stone. Cholecystectomy is performed before discharge. Gallstone pancreatitis warrants urgent ERCP.
__________________________ should be suspected in a pt with gallstone pancreatitis who also has fecers, RUQ pain, jaundice, altered mental status, and hypotension
acute cholangitis
