Gallstone disease Flashcards
Risk factors for Gallstones
Female Fair Forty Fertile (pregnant, COCP) Fat
Gallstone composition
Bile pigment stones 5%
Cholesterol stones 20%
Mixed stones 75%
Cholesterol gallstones
Large
Often solitary
Pigment gallstone
Small
Fragile
Calcium bilirubinate
Associated with haemolysis
Mixed gallstones
Often multiple
Complications of gallstones
Biliary colic Acute cholecystitis Chronic cholecystitis Mirizzi's syndrome Obstructive jaundice Pancreatitis Cholangitis Gallstone ileus
Biliary colic pathogenesis
Gallstone impacted in neck of gallbladder (Hartmann’s pouch)
Gallbladder spasm
Biliary colic presentation
RUQ pain - radiates to back / scapula
Attacks < 6 hrs
Worse with fatty food
Sweating
Investigations for biliary colic
Urine - bilirubin
Bloods
US - acoustic shadow
Management of biliary colic
Conservative:
- Rehydrate
- Nil by mouth
- Analgesia
Surgical - laproscopic cholecystectomy
Acute cholecystitis pathogenesis
Gallstone impaction in Hartmann’s pouch
+ inflammation
+/- Empyema
Acute cholecystitis presentation
Contiuous RUQ pain
Radiates to right scapula + epigastrum
Fever
Vomiting
Acute cholecystitis examination findings
Local peritonsim RUQ
Tachycardia
Shallow breathing
Murphy’s sign
Acute cholecystitis investigations
Urine - bilirubin
↑WCC
US
MRCP (MRI cholangiopancreatography)
Conservative management of acute cholecystitis
Nil by mouth
Fluid resus
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
