Gallstone disease Flashcards
1
Q
What is the daily secretion volume of bile?
A
500mL per day
2
Q
What hormones control bile secretion?
A
Secretin and CCK/gastrin
3
Q
List the main components of bile.
A
- Cholesterol
- Bile salts/acids
- Bile pigments (bilirubin and biliverdin)
- Phospholipids (Phosphatidylcholine = lecithin)
- Alkaline solution
- Xenobiotics
4
Q
How is plasma cholesterol regulated?
A
- Hepatic synthesis from acetate under influence of HMG CoA enzyme
- Biliary excretion as cholesterol, bile salt, or cholesterol esters
5
Q
What are the primary bile acids?
A
- Cholic acid
- Deoxycholic acid
- Chenodeoxycholic acid
- Lithocholic acid
6
Q
Fill in the blank: Bile acid is synthesised from ______ in the liver.
A
cholesterol
7
Q
What is the action of bile salts?
A
Form micelles to emulsify fat and allow digestion and absorption of fat-soluble vitamins (ADEK)
8
Q
How is bilirubin formed?
A
By breakdown of hemoglobin in tissues (spleen and reticuloendothelial system)
9
Q
What happens to free unconjugated bilirubin in the liver?
A
It is conjugated to glucuronic acid to form bilirubin glucuronide
10
Q
What is enterohepatic circulation?
A
Reabsorption of bile components in the intestine and excretion again by the liver
11
Q
What is the balance necessary to prevent gallstone formation?
A
A delicate balance between bile acids, phospholipids (lecithin), and cholesterol
12
Q
Define cholelithiasis.
A
Formation of gallstones
13
Q
What is biliary colic?
A
Gallstones transiently impacted in cystic duct causing pain, but no infection
14
Q
What are the risk factors for cholesterol gallstones?
A
- Fat (obesity)
- Forty (age)
- Female
- Fertile
- Fair
15
Q
What conditions can lead to biliary stasis?
A
- Starvation
- TPN
- Pregnancy
- Cystic fibrosis
16
Q
True or False: Mixed gallstones comprise 90% of all stones.
A
True
17
Q
What are the two types of pigmented gallstones?
A
- Brown gallstones
- Black gallstones
18
Q
What is the primary cause of calculus cholecystitis?
A
Sustained gallstone impaction in cystic duct or Hartmann’s pouch
19
Q
What are common organisms involved in secondary infection in cholecystitis?
A
- E. coli
- Klebsiella
- Enterococcus
20
Q
What is Murphy’s sign?
A
Abrupt cessation of inspiration upon palpation of RUQ
21
Q
What is choledocholithiasis?
A
Gallstones in the CBD
22
Q
What percentage of patients undergoing surgery for symptomatic GB stones will also have choledocholithiasis?
A
12%
23
Q
What is the primary management for symptomatic choledocholithiasis?
A
ERCP for gallstone extraction and elective cholecystectomy
24
Q
Fill in the blank: The majority of secondary choledocholithiasis originates from ______.
A
the gallbladder
25
What is the characteristic presentation of acute cholecystitis?
RUQ pain, often with a history of biliary colic
26
What is the diagnostic procedure of choice for cholecystitis?
Ultrasound
27
What is the typical treatment for uncomplicated acute cholecystitis?
Cholecystectomy + IOC
28
What complication can arise from prolonged cholecystitis?
Gangrene or perforation of the gallbladder
29
What is the indication for placing a T-tube?
Failed choledochotomy
## Footnote
T-tube may also be inserted after clearance of stones.
30
What is the recommended action if CBD is less than 5mm?
Open if expertise is low, several gallstones are present, or gallstones are large
## Footnote
This indicates complications during procedures.
31
What are the indications for post-operative ERCP?
Failed cystic duct exploration, choledocholithiasis after laparoscopic cholecystectomy, high-risk patients with ascending cholangitis
32
What are common complications of ERCP?
Bleed, pancreatitis, cholangitis, perforation
## Footnote
Complications occur in about 5% of cases.
33
What is the mortality rate associated with complications from ERCP?
1%
34
What is acute cholangitis also known as?
Ascending cholangitis, cholangitis
35
What is the primary cause of acute cholangitis?
Infection of the bile ducts
36
What are the most common causes of biliary obstruction leading to acute cholangitis?
Choledocholithiasis (60%), stricture, neoplasm (cholangioCa), pancreatic pseudocyst or pancreatitis, iatrogenic factors
37
What are the common bacteria associated with biliary infections?
Klebsiella, Enterococcus, E. coli, Enterobacter, Proteus, Pseudomonas, Serratia
38
What is Charcot’s triad in the context of acute cholangitis?
Fever, RUQ pain, jaundice
39
What additional symptoms are present in Reynolds' pentad?
Shock, confusion
40
What laboratory findings are indicative of acute cholangitis?
↑ WBC, neutrophilia, obstructive LFTs (↑ conjugated bilirubin, ↑ ALP/GGT)
41
What is the initial management for acute cholangitis?
NBM ± NGT, IVF and electrolyte resuscitation, IV antibiotics
42
What is the definitive treatment for all patients with acute cholangitis?
Cholecystectomy unless contraindicated
43
What is gallstone ileus?
A rare form of small bowel obstruction caused by an impaction of a gallstone within the small intestine
44
What is the epidemiology of gallstone ileus?
Rare
45
What is the primary cause of gallstone ileus?
Cholecystitis leading to erosion through the gallbladder fundus and formation of a cholecysto-enteric fistula
46
What is Bouveret’s Syndrome?
Gastric outlet/duodenal obstruction caused by a large gallstone passing through a cholecystogastric or cholecystoduodenal fistula
47
What imaging findings are associated with gallstone ileus?
Rigler’s Triad: pneumobilia, small bowel obstruction, gallstone
48
What is Mirizzi syndrome?
Extrahepatic extrinsic compression of the common hepatic duct or CBD by gallstones in the cystic duct or Hartmann’s pouch
49
What are the types of Mirizzi syndrome?
Type I: no fistula, Type II-IV: fistula present, Type V: fistula into CBD/CHD and into duodenum
50
What is the surgical management for Type I Mirizzi syndrome?
Simple cholecystectomy
51
What should be done if a fistula is present in types II-IV of Mirizzi syndrome during laparoscopic cholecystectomy?
Convert to open surgery, place T-tube through the fistula, and perform intraoperative cholangiography
52
What are the reasons for routine intraoperative cholangiography (IOC)?
Maintain skill, identify choledocolithiasis, confirm anatomy, reduce severity of biliary injury
53
What is the prevalence of gallstones in men and women?
12% in men, 24% in women
54
What percentage of individuals with gallstones are symptomatic?
10-30%
55
What are the main compositions of gallstones?
* Cholesterol
* Mixed (80%)
* Pigment
56
What is the composition of mixed gallstones?
>50% cholesterol
57
What percentage of gallstones have enough calcium to be radio-opaque?
10-20%
58
What are the risk factors for cholesterol stones?
* Female (2x risk)
* Increasing age
* Fertility – increasing parity, OCP
* Obesity
* Ileal disease/resection
* Cirrhosis
* CF
* DM
* Long term TPN
* Impaired GB emptying
* Clofibrate
* Heart transplant
* Periods of low fat dieting
* Family history
59
What are the two types of pigmented stones and their compositions?
* Black → polymerized and oxidized
* Brown → unpolymerized
60
How do black pigmented stones develop?
Develop in sterile gallbladder bile due to hyperbilirubinaemia from haemolysis
61
How do brown pigmented stones form?
Form due to stasis and anaerobic infection which hydrolyses bile lipids
62
What is Oriental hepatolithiasis?
A form of brown stone disease
63
What factors enhance cholesterol stone formation?
* Pronucleating agents (glycoproteins, immunoglobulins)
* Gallbladder stasis due to dysmotility
64
What conditions can lead to gallbladder stasis?
* Prolonged fasting
* TPN
* Vagotomy
* Somatostatin analogues
65
What is the pathophysiology of cholecystolithiasis?
* Gallstone becomes impacted in gallbladder neck
* Gallbladder spasm then relaxes, allowing stone to fall back → biliary colic
66
What happens if a gallstone becomes trapped?
Causes persistent pain and changes in trapped bile due to stasis leading to chemical inflammation
67
What are the clinical presentations of gallstone disease?
* Sharp, constant RUQ pain
* Sudden onset
* Related to food
* Worse with inspiration or movement
* Radiates to back or tip of shoulder blade
* Associated with nausea/vomiting, loss of appetite
68
What examination findings are associated with gallstone disease?
* Tender RUQ
* Positive Murphy’s sign
* Palpable inflammatory mass
* Fevers/tachycardia
* RUQ peritonism
* Jaundice
69
True or False: Jaundice suggests choledocholithiasis or Mirizzi syndrome.
True
70
Fill in the blank: Gallstones are composed of calcium hydrogen ________ in pigmented stones.
bilirubinate
71
What is choledocholithiasis?
The presence of stones in the common bile duct (CBD)
## Footnote
Stones can pass from the gallbladder (GB) into the CBD, causing various complications.
72
What are the pathophysiological consequences of impacted stones in the distal CBD?
* Obstructive jaundice
* Pancreatitis
* Stasis of bile leading to cholangitis
## Footnote
Intermittent impaction can cause pain due to spasm of the sphincter of Oddi.
73
What is Charcot's triad?
* RUQ pain
* Jaundice
* Fever
## Footnote
It is a clinical presentation associated with cholangitis.
74
What additional symptoms make up Reynolds' pentad?
* Hypotension
* Mental obtundation
## Footnote
These symptoms indicate severe cholangitis.
75
What examination findings are associated with choledocholithiasis?
* RUQ tenderness
* Jaundice
* Gallbladder not usually palpable
## Footnote
This is known as Courvoisier's law.
76
What are common bacteria involved in cholangitis?
* E. coli
* Klebsiella
* Enterobacter
* Bacteroides
## Footnote
These bacteria can translocate from the duodenum into static bile.
77
What laboratory tests are important in investigating choledocholithiasis?
* LFTs (ALP/GGT raised more than ALT/AST)
* High bilirubin
* FBC
* Lipase
## Footnote
These tests help assess liver function and the presence of pancreatitis.
78
What imaging modality is often used to assess gallstones and cholecystitis?
Ultrasound
## Footnote
It can detect gallstones and features of cholecystitis, such as a thickened wall.
79
What is the purpose of a HIDA scan?
To evaluate gallbladder function and diagnose cholecystitis
## Footnote
It uses Tc-labeled hydroxy-imino-diacetic acid to assess gallbladder activity.
80
What is the management for asymptomatic stones?
No treatment
## Footnote
Asymptomatic stones typically do not require intervention.
81
What is the standard treatment for symptomatic gallstones?
Laparoscopic cholecystectomy
## Footnote
This is considered the standard of care for symptomatic gallstones and acute cholecystitis.
82
What is choledochoduodenostomy?
A surgical procedure to create a connection between the common bile duct and the duodenum
## Footnote
It is indicated for primary bile duct stones.
83
What are the indications for ERCP?
* Post cholecystectomy CBD stones
* Failed transcystic CBD exploration
* Severe cholangitis
## Footnote
ERCP is a minimally invasive procedure with a high success rate.
84
What are the grades of cholangitis?
* Grade 1: mild
* Grade 2: moderate (needs 2/5 criteria)
* Grade 3: severe (1/6 criteria)
## Footnote
Criteria include elevated WCC, temperature, bilirubin, and other clinical signs.
85
What is biliary dyskinesia?
Symptoms of biliary disease without ultrasound-demonstrable stones
## Footnote
Diagnosis is often confirmed using a CCK-stimulated HIDA scan.
86
What defines Sphincter of Oddi dysfunction?
Biliary tract pain with normal LFTs and recurrent pancreatitis
## Footnote
It may be due to structural or functional abnormalities of the sphincter.
87
What are the types of Sphincter of Oddi dysfunction?
* Type 1: abdominal pain, obstructive LFTs, biliary dilatation
* Type 2: pain with 1-2 of above
* Type 3: recurrent biliary pain only
## Footnote
Diagnosis involves manometry and response to CCK.
88
What is the typical success rate of endoscopic sphincterotomy for Sphincter of Oddi dysfunction?
60-80%
## Footnote
This procedure is often used to relieve symptoms.
