Gallstone disease Flashcards by K D

Risk factors for Gallstones

Female
Fair
Forty
Fertile (pregnant, COCP)
Fat

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Gallstone composition

Bile pigment stones 5%
Cholesterol stones 20%
Mixed stones 75%

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Cholesterol gallstones

Large

Often solitary

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Pigment gallstone

Small
Fragile
Calcium bilirubinate
Associated with haemolysis

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Mixed gallstones

Often multiple

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Complications of gallstones

Biliary colic
Acute cholecystitis
Chronic cholecystitis
Mirizzi's syndrome
Obstructive jaundice
Pancreatitis
Cholangitis
Gallstone ileus

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Biliary colic pathogenesis

Gallstone impacted in neck of gallbladder (Hartmann’s pouch)

Gallbladder spasm

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Biliary colic presentation

RUQ pain - radiates to back / scapula
Attacks < 6 hrs
Worse with fatty food
Sweating

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Investigations for biliary colic

Urine - bilirubin
Bloods
US - acoustic shadow

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Management of biliary colic

Conservative:

Rehydrate
Nil by mouth
Analgesia

Surgical - laproscopic cholecystectomy

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Acute cholecystitis pathogenesis

Gallstone impaction in Hartmann’s pouch
+ inflammation
+/- Empyema

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Acute cholecystitis presentation

Contiuous RUQ pain
Radiates to right scapula + epigastrum
Fever
Vomiting

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Acute cholecystitis examination findings

Local peritonsim RUQ
Tachycardia
Shallow breathing
Murphy’s sign

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Acute cholecystitis investigations

Urine - bilirubin
↑WCC
US
MRCP (MRI cholangiopancreatography)

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Conservative management of acute cholecystitis

Nil by mouth

Fluid resus

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Medical management of acute cholecystitis

Analgesia

Abx: Cefuroxime + Metronidazole

Surgical management of acute cholecystitis

Laproscopic cholecystectomy

Acute cholecystitis empyema presentation and management

Fever
RUQ mass

Cholecystostomy - percutaneous drainage

Chronic cholecystitis presentation

Vague upper abdo discomfort
Distention
Nausea
Flatulence
Worse with fatty food

Chronic cholecystitis investigations

AXR
US - gallstones, fibrotic, shrunken gallbladder
MRCP

Management of chronic cholecystitis

Medical: bile salts
Surgical: cholecystectomy

Rarer gallstone disease

Mirizzi’s syndrome

Gallstone ileus

Mirizzi’s syndrome

Rare
Large stone in gallbladder compresses common hepatic duct
Leads to obstructive jaundice

Gallstone ileus

Rare
Large stone errodes from gallbladder to duodenum
May impact in distal ileum and cause obstruction
Rigler’s triad

Rigler's triad

Associated with gallstone ileus Pneumobillia Small bowel obstruction Gallstone in RLQ

Management of gallstone ileus

Stone removal via enterotomy

Bilirubin level where jaundice is noticable

50 - 75 mM | Seen at tongue frenulum first

Causes of obstructive jaundice

Stones Cancer of pancreas head Mirizzi's syndrome Drugs - COCP, sulfonylureas

Obstructive jaundice presentation

Jaundice Dark urine Pale stools (steatorrhoea) Itch

Obstructive jaundice investigations

``` Urine - dark, bilirubin ↑WCC Hepatorenal syndrome ↑conjugated bilirubin ↑ALP and ↑AST/ALT ↑INR (decreased vit K) Immune: AMA, ANCA, ANA AXR US MRCP ```

Management of gallstone obstructive jaundice

Conservative: - Monitor LFTs and wait for stone passage Surgical: - ERCP with sphincterotomy and stone extraction - Cholecystectomy

Ascending cholangitis gallstone location

Common bile duct

Ascending cholangitis presentation

Charcot's triad | Reynolds pentad

Charcot's triad

Fever RUQ pain Jaundice

Reynolds pentad

Charcot's triad + shock + confusion | Charcot's triad = Fever, RUQ pain, Jaundice

Management of ascending cholangitis

Cefuroxime + Metronidazole ERCP with sphincterotomy and stone removal