Gallstone Disease Flashcards
What is the incidence of gallstones in >50s?
10%
What are some RFs for gallstone disease?
What are the major components of bile? Where is bile stored? Where is it secreted and what controls its secretion?
What causes the release of CCK?
What are the risks for developing a cholesterol gallstone vs a bile salt stone?
How is gallstone formed? What are the types of gallstones? What is the most common?
What is the typical presentation of gallstones?
asymptomatic
What causes biliary colic. Why is it a colicky type pain. (why is the pain not constant)
A patient with chronic cholecystitis presents with intermittent N+V, bloating, constipation and generalised abdominal pain. What is the most likely cause? How does it explain this presentation
gallstone ileus - usually gets stuck at ileocaecal valve, but it can also erode through the gallbladder causing a cholecystoduodenalfistula.
A patient has a previous history of biliary colic and has now presented with CONSTANT SEVERE epigastric pain. What is a possible reason for her new symptoms?
A patient has a recent history of biliary colic and acute cholecystitis. She now presents with fever, tachycardia, tachypnea and hypotension. There is no dilation of the biliary tree on US. Why did this occur (give 2 possibilities)? How will it be managed?
Or can be perforated leading to peritonitis. If exam was performed and no rebound tenderness + present bowel sounds, it’ll be empyema only
A patient has a recent history of biliary colic and acute cholecystitis. She now presents with fever, tachycardia, tachypnea and hypotension. Given that the most likely cause of her presentation is an empyema of the gallbladder, what are the possible sequelae if left untreated? Include the management of the sequelae.
A patient with a recent history of biliary colic presents to the clinic with a large tense RUQ mass. Why do you think this occured?
What triad is used for ascending cholangitis?
Charcot
What is charcot’s triad and Reynolds’ pentad? What are they used to diagnose?
Charcot triad - RUQ pain, fever, jaundice
Reynold’s pentad - +hypotension, altered GCS
ascending cholangitis
A patient has a recent history of biliary colic and acute cholecystitis. She now presents with fever, jaundice and RUQ pain. What is the most likely cause of her presentation?
A patient has a recent history of biliary colic and acute cholecystitis. She has not received any treatment thus far. She now reports N+V, acute constant epigastric pain radiating to her back and relieved by leaning forward. Why did this occur?
Outline the possible sequelae of a stone in the gallbladder, explaining their symptom presentation.
Go off and include the management if you want but we will go through them separately.
What is the ROME criteria and what is it used for?
A patient presents with non-specific symptoms. She had an US of her gallbladder and a stone was found. She was then sent for cholecystectomy but her symptoms still persisted. What is the most important ddx that may be causing her symptoms and needs to be ruled out? How is this ruled out?
This is most definitely 100% not the most important diagnosis to rule out 😂😂😂
What causes biliary colic? What are the typical symptoms?
You are investigating a patient with gallstone disease. What findings would you expect to see on U/S gallbladder?
You are investigating a patient with biliary colic. What would you expect to see on LFTs? Why?
Raised ALP due to transient duct occlusion but bilirubin and transaminases.
What is the purpose of an MRCP in the case of biliary colic?
Used if stone is unclear on U/s or show a defect in the biliary tree.
What investigations would you order to confirm your dx of biliary colic?
What is the aim of surgical treatment of biliary colic?
prevent recurrence => more important if recurrent biliary colic
A 42-year-old female presents to the emergency department with intermittent right upper quadrant abdominal pain for the past 3 months.
History of Present Illness:
The pain is described as sharp, colicky, and radiating to the right shoulder blade. Episodes last approximately 1–2 hours and are often triggered by fatty meals. She denies fever, chills, nausea, or vomiting during these episodes. No recent weight loss or changes in bowel habits are reported.
Past Medical History:
Hypertension (well-controlled on medication).
No prior surgeries.
Family History:
Mother with a history of gallstones.
Social History:
Non-smoker.
Rare alcohol use.
Review of Systems:
Negative for fever, jaundice, or dark urine.
No significant weight loss or anorexia.
Physical Examination:
Vital signs: BP 125/80 mmHg, HR 78 bpm, Temp 36.8°C.
Abdominal exam: Mild tenderness in the right upper quadrant without guarding or rebound tenderness. No palpable masses. Murphy’s sign negative.
No scleral icterus or jaundice.
Initial Laboratory Results:
Complete blood count (CBC): Normal.
Liver function tests (LFTs): Within normal limits.
Lipase: Normal.
Imaging:
Ultrasound of the abdomen: Gallbladder wall appears normal with no pericholecystic fluid. Multiple small echogenic foci with posterior acoustic shadowing consistent with gallstones are noted. No bile duct dilation.
What the management of you likely dx.
What is the difference between for ERCP vs MRCP?
ERCP: Best for cases requiring intervention (stone removal, stent placement, biopsy). However, it carries higher risk and should not be used solely for diagnosis unless therapeutic intent is expected.
MRCP: Best for non-invasive diagnosis to confirm biliary or pancreatic duct pathology. It is safer and highly sensitive but not therapeutic.
What are your ddx for biliary colic?
What are the RFs for acute cholecystitis?
What is acute cholecystitis? What does this occur?
Describe the pathogenesis of acute cholecystitis.
Why does acute cholecystitis cause shoulder pain?
phrenic nerve irritation
What is Collin’s sign in the context of acute cholecystitis?
RUQ Pain radiating to right shoulder due to phrenic nerve irritation.
What is Murphy’s sign in the context of acute cholecystitis? What does it indicate?
INDICATES LOCAL PERITONITIS
List the S+S of acute cholecystitis.
- RUQ Pain radiating to right shoulder worse after fatty meals do to CCK release
- n+v
- tachycardia
- tachypnoea
- pyrexia
- anorexia
- RUQ tenderness guarding
- ± jaundice on SBR not clinically (MILD when stone in gallbladder)
- gallbladder may be palpable
- murphy’s sign ( local peritonism)
At what SBR does jaundice becoming a clinical finding?
What gallbladder diseases typically cause jaundice?
> 40 mmol/L
A patient has all the symptoms of acute cholecystitis but murphy’s sign is not positive. What is the likely dx?
What lab finding would lead you to suspect there is a stone in the CBD?
Very increased SBR - may be at the level to see clinical jaundice (>40mmol/L)
Give the top 3 investigations (+findings on them) to diagnose acute cholecystitis?
When is a cholecystectomy performed in the setting of acute cholecystitis? Why?
performed either within 72 hrs or after 6-8 weeks when inflammation settles as the inflammation makes the surgery more difficult (layers of the inflamed organ stick to surrounding structures making it harder to separate and increased the risk of adhesions, also everything looks the same - its all inflamed)
When is a percutaneous cholecystostomy used over a cholecystectomy?
Outline the management of acute cholecystitis.
What are the complications of acute cholecystitis?
Cholecystectomies are usually performed laparoscopically. What are the indications for cholecystectomy?
Cholecystectomies are usually performed laparoscopically. What are the contraindications for cholecystectomy?
Cholecystectomies are usually performed laparoscopically. What are the risks of cholecystectomy?
What is a gallbladder empyema? How does it present?
- RUQ Pain radiating to right shoulder worse after fatty meals do to CCK release
- n+v
- tachycardia
- tachypnoea
- pyrexia
- anorexia
- RUQ tenderness guarding
- ± jaundice on SBR not clinically (MILD when stone in gallbladder)
- gallbladder may be palpable
- murphy’s sign ( local peritonism)
How do you manage acute cholecystitis complicated by gangrene?
How would you investigate for a gallbladder empyema?
same as acute cholecystitis but very increased WCC and CRP
Dx - US/CT (better but more radiation)
How would you manage a gallbladder empyema?
Pigtail catheter specifically (T-tube only for bile duct pathologies
What is gangrene of the gallbladder and how is it diagnosed (2)? Give the specific findings
1) exam: negative murphy’s sign despite all signs and symptoms of acute cholecystitis
2) US showing air within gallbladder (just like in a cholecystoduodenal fistula)
What does this image show?
percutaneous cholecystostomy tube
What does this image show?
t tube
You are operating on a gangrenous gallbladder when the gallbladder is accidentally punctured and spillage begins to complicate the surgery. What was being performed here specifically (im not looking for percutaneous IR drainage).How would you manage this?
You are operating on a gangrenous gallbladder. At the start of the surgery, you determine that there is too much inflammation and the surgery needs to be abandoned. What is your action plan for this patient now?
How is gangrene of the gallbladder managed?
What are the S+S of a perforated Gallbladder?
What does this image show?
pigtail catheter drain
How would you investigate for a perforated gallbladder?
Outline the Management of a perforated gallbladder?
What is chronic cholecystitis and what are its key clinical features?
How you dx and manage chronic cholecystitis?
What are the complications of chronic cholecystitis?
What is a mucocele?
How does a mucocele present?
Why doesn’t Courvoisier’s law apply?
What is courvoisier’s law?
In a patient with painless jaundice and a palpable, non-tender gallbladder, the cause is more likely to be malignant obstruction of the biliary tree (e.g., pancreatic or biliary cancer) rather than gallstones.
How would you manage a mucocele?
Where can a gallstone ileus extend to?
What is the specific sequelae of a gallstone illeus that is lodged in the duodenum rather than anywhere else? What is this sequelae called?
Bouveret’s syndrome - gastric outlet obstruction - intermittent projectile vomiting
Typically occurs in elderly with multiple comorbidities and large gallstones (it is a relatively rare phenomenon)
What is the sequelae of a gallstone illeus that extends to the terminal ileum?
SBO
What is a gallstone ileus?
How can a gallstone ileus present?
How would you dx gallstone ileus?
Outline the management of a gallstone ileus.
During laprascopic removal of obstructing stone in the case of a gallstone ileus, is the fistula resected? explain the rationale.
What are the causes of obstructive jaundice? Which is the most common cause?
How does obstructive jaundice presentation?
Why is the gallbladder not palpable in ascending cholangitis?
How would you diagnose obstructive jaundice?
What is the main surgical technique used to treat obstructive jaundice? Explain the technique! if this technique is difficult to perform, what is the next option?
Outline the management of mirizzi syndrome.
It is a laparoscopic cholecystectomy not only removal of the stone
What is the indication for t tube use in gallbladder disease? What materials are t tubes made from? Which material should remain in for longer. Why?
A patient presenting with obstructive is deemed unfit for ERCP. Why may this be? What is the best treatment option for her?
Reasons for no ERCP: difficult retrieval, surgery along path of ERCP, not fasting, active vomitting, duodenal diverticula.
How would you define ascending cholangitis?
What are the causes of ascending cholangitis?
Explain the pathophysiology of ascending cholangitis.
Describe the common presentation of ascending cholangitis.
What exam findings would you be looking for in ascending cholangitis?
Which of the followings signs is going to present first:
pale stools or dark urine?
why?
What would you expect to find on US gallbladder in ascending cholangitis?
CD dilatation ± stones but not usually seen due to duodenal or intestinal gas.
A patient presents with Reynolds’s pentad clearly. On US CBD, there is no evidence of any stones.
Why is seeing stones less likely in ascending cholangitis?
If the stone is just small, give 3 ways you can get a more accurate picture of the CBD
Stones difficult to see due to excessive amounts of gas and inflammation in the area.
Endoscopic US Gallbladder
MRCP
ERCP
Does MRCP involve the use of a contrast?
No static fluids (bile) naturally white on MRCP
When is a percutaneous transhepatic cholangiography indicated for investigation of ascending cholangitis?
If T-tube already in situ to look for complications
Or If MRCP/ ERCP has failed.
What would you see on MRCP in ascending cholangitis?
stone will show a filling defect.
How would you investigate for ascending cholangitis?
Outline the management of ascending cholangitis. Include the indications and step up management.
What is the most common site for cholangiocarcinoma? Where does it metastasise to?
What would you find on histopathology of cholangiocarcinoma?
usually adeno
What are the RFs for cholangiocarcinoma?
What are the tumour markers for cholangiocarcinoma?
Ca19-9, CEA
How would you investigate for cholangiocarcinoma?
same as before (image)
+ staging via CT
Can a patient with biliary disease and jaundice have bilious vomitting?
no cause no bile
What are the complications of cholangiocarcinoma?
Outline the management of cholangiocarcinoma.
What is the main complication of a mucocele?
If a mucocele gets infected, it causes gangrene which will liquify => -ve murphy sign and no more rigid RUQ mass
What is the normal width of the gallbladder?
What would be considered distended?
What is normal GB wall thickness?
What would be considered thickened?
What is the normal diameter of the CBD
What is considered dilated?
GB width
Normal 3-4cm
Distended is >6cm
GB wall thickness
Normal is <3mm
Thickened >4mm
CBD diameter
Normal <6 (unless post-cholecystectomy, then <10)
Dilated >6
What are the findings on US that will hint towards gallstone disease
1) Acoustic shadowing (or gallstones)
2) Large gallbladder >6cm
3) Dilated CBD proximal to obstruction >6mm (in most)
4) GB wall thickening >4mm
5) Pericholecystic fluid
6) Sonographic Murphy’s sign
What is the diameter of a normal bile duct?
<6mm
Note after cholecystectomy normal becomes under 1cm
A patient presented with acute cholecystitis and has been treated appropriately. They are sent home and booked an elective cholecystectomy in 6 weeks. Youve explained it to the patient and are giving safety netting advice to come back if symptoms develop. What is the risk that the patient comes back?
Within the 6 week timeframe, there is a 30% risk of another attack
