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Surgery block > Gallstone diseases > Flashcards

Gallstone diseases Flashcards

1
Q

Describe the basic anatomy of the biliary system

A

Right and left hepatic duct
Into the common hepatic duct
The gallbladder drains into the cystic duct
Cystic and CHD combine to form the common bile duct
Drained into by the pancreatic duct
Form the Ampulla of Vater controlled by the sphincter of Oddi.

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2
Q

What is the function of the gallbladder?

A

Stores and concentration bile from the liver
Bile is responsible for breaking down fat into fatty acids

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3
Q

What is bile made up of?

A

Cholesterol, bile salts and bile pigements (bilirubin)

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4
Q

What is the basic composition of gallstones?

A

Hardened bile deposits

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5
Q

What causes gallstone formation?

A

Imbalances in the chemical make up of bile
Most commonly very high cholesterol levels
Slow GB emptying can also inc conc of bile causing stone formation

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6
Q

What is the prevalence of gallstones?

A

10% of adults have cholelithiasis (gallstones)
Only 10% of these develop signs and symptoms
Hence are a common incidental finding

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7
Q

What are the three different types of gallstones?

A

Pigment stones
Cholesterol stones
Mixed stones

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8
Q

What are pigment stones in the gall bladder?

A

Small and dark in colour (like small black shiny pebbles)
<10% prevalence
Too much bilirubin (aka in hemolysis)

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9
Q

What are cholesterol stones in the gallbladder?

A

larger, yellow-brown colour
Most common type of gallstones >90%
Too much cholesterol
Increase with obesity, age, familial hypercholesterolemia.

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10
Q

What are mixed stone, gallstones?

A

Variable colour
Essentialy cholesterol gallstones with a high concentration of calcium salts.
Tend to be more patchy in appearance - yellow with white, brown, black spots.

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11
Q

What are the three main gallstone conditions?

A

Biliary colic
Cholecystitis
Acute cholangitis

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12
Q

What is biliary colic?

A

Temporary obstruction of the cystic duct of common bile duct by a gallstone
In the absence of infection/inflammation

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13
Q

What are the symptoms of biliary colic?

A

Intermittent cramp like pain = colic
Norm in the RUQ/central abdo pain (may refer to shoulder tip)

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14
Q

What are the treatments available for biliary colic?

A

Analgesia
+/- elective cholecystectomy

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15
Q

What is a cholecystecomy?

A

Typically is a laparoscopic removal of the gall bladder.

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16
Q

What factors help decide if a patient with biliary colic is suitable for an elective cholecystectomy?

A

Frequency and severity of symptoms
Whether analgesia helps control their symptoms?
Suitable for surgery - justify the risks
How does biliary colic affect their quality of life?

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17
Q

What is cholecystitis?

A

Inflammation of the gallbladder mainly due to gallstones blocking the cystic duct resulting in inappropriate drainage of bile causing inflammattion

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18
Q

What are the main risk factors for acute cholecystitis?

A

(the 4 fs)
Female
Fat
Forty
Fertile
Also high fat diet and inactive lifestyle

19
Q

What are the symptoms of cholecystitis?

A

RUQ/epigastric pain - worse after eating esp fatty foods, persistent and severe, can radiate to right shoulder (if irritates the diaphragm)
Fever
Jaundice is not common as CBD not obstructed although can occur as mild in <10%

20
Q

Why do people with colecystitis typically get worse pain after eating?

A

Presence of fatty foods in the small intestine stimulates the release of CCK
CCK stimulates gallbladder contraction to release bile
Contraction of the inflamed gallbladder are painful.

21
Q

What is CCK?

A

A peptic hormone linked to the gastrointestinal system

22
Q

What are the different effects of CCK?

A

Action mediated by CCK1 receptor
Gallbladder - stim contraction of GB and relaxation of sphincter of oddi - bile into duo
Pancreas - inc trypisn secretion from acinar cells, inc bicarb and fluid from ductal cells, increase pancreatic mass - helps digest food
Stomach - relaxes proximal stomach contract pylorus - delay emptying
Brain - induces satiety.

23
Q

How is Murphys sign relevant to cholecystitis?

A

Sensitive - almost all cases, so negative result can be used to rule out cases with confidence
Not very specific
Process - place hand on RUQ under ribs, ask patient to take a deep breath, repeat with LUQ, positive is pain on RUQ but not LUQ.

24
Q

What investigations should be done for a suspected cholecystitis?

A

Full set of obs - septic?
Bloods - raised WCC/CRP
USS abdo - gold standard - thick wall GB

Amylase - rule out pancreatitis
LFts - acute cholangitis
Pregnancy test - ectopic
CXR - RLL pneuomonia

25
Q

What is the initial treatment for cholecystitis in A&E?

A

Antibiotics (IV or roal) - treat secondary infection common Co-amoxiclav
Analgesia
+/- IVT (for dehydration, low BP or if NBM before surgery)
May consider a cholecystotomy

26
Q

What is the definitive care for acute cholecystitis?

A

Cholecystectomy
Can be acute of delayed
Timing dependent on several factors.

27
Q

What are the indications for an emergency cholecystectomy?

A

Regardless of surgical risk if:
Evidence of GB necrosis or perfroation
Very acutely unwell/life-threatening conditions despite initial non-operative management.

28
Q

What is the non-emergency surgical management of patients with acute cholecystitis?

A

Must be good surgical cancidaitations
Recomend cholecytectomy during initial hospitalisation often as early as possible within 72 hours of symptoms onset
Earlier surgery has reduced perioperative morbidity and mortality.

29
Q

What makes a poor surgical candidate with cholecystitis?

A

Have no indications for emergency cholecystectomy, should be managed non operatively.
If resolves with non-operative treatment reassess the patients risk for surgery at a later date then offer as surgery is definitive treatment, without the risk of reoccurence is very high.

30
Q

What is a cholecystostomy?

A

Surgical procedure that creates an opening in the gallbladder to drain it or remove gallstones.
Inserted catheter is used to drain bile.
Is less invasive than a cholecystectomy, so often used to provide temporary relief for patients who were not considered good surgical candidates.

31
Q

Define acute cholangitis

A

A clinical syndrome that develops as a result of stasis and infection in the common bile duct.
Also known as ascending cholangitis (as prevents drainage of the liver)

32
Q

What are the main causes of acute cholangitis?

A

Obstruction of the CBD - commonly by gallstones, malignancy (Head of pancrea tumour or cholangiocarcinoma),
Post ERCP

33
Q

What are the key symptoms of acute cholangitis?

A

Follows Charcots triad
Fever, RUQ pain, Jaundice

May also present with sepsis as an acute abdomen

34
Q

How common are each of Charcots traid symptoms in a case of acute cholangitis?

A

80% Abdo pain
80% fever
60-70% Jaundice - including dark urine and pale stools)

35
Q

What is Reynolds Pentad?

A

Fever, confusion, shock, RUQ pain, Jaundice,
Can indicate more serious cholangitis potentially septic.

36
Q

What blood investigations should be done for acute cholangitis?

A

FBCs - raised WCC
CRP - raised
LFTs - raised ALP, GGT and bilirubin - obstructive picture
Blood cultures and lactate is suspect sepsis
Amylase - rule out pancreatitis

37
Q

What investigations should be done for suspected acute cholangitis?

A

Bloods (own slide)
USS abdo - CBD dilation +/- stones
CT abdo - is clinical suspicion of cholangitis but USS normal
Pregnancy test - all women of childbearing age
MRCP and ERCP

38
Q

What is MRCP?
What is its function?

A

Magnetic resonance cholangiopancreatography
Special MRI scan - detailed imaging of the biliary tree, gallbladder and pancrease
Used when clinical suspicion of cholangitis but USS and CT fail to provide diagnostic certainty
Non-invasive

39
Q

What is an ERCP?

A

Endoscopic retrograde cholangiopancreatography
To visualise biliary tree
Diagnostic and curative - takes biopsies, remove stents, insert stents
Counter intuitively can cause acute cholangitis by introducing infection.

40
Q

What is the treatment for mild acute cholangitis?

A

Admit to ward for monitoring
Antibiotics
Supportive care - IVT, analgesia

41
Q

What is the treatment for more severe cases of acute cholangitis?

A

As mild cases (ward monitoring, antibiotics, IVT and analgesia)
Plus billiary drainge via ERCP, is gallstone blockage stone removal and if malignancy stent insertion.

42
Q

How are the underlying causes of acute cholangitis commonly cured?

A

If gallstones - elective cholecystectomy to prevent further comp of gallstone disease
If malignant cause - refer to oncology.

43
Q

How can the symptoms be used to differentiate between biliary colic, cholecystitis and cholangitis?

A

Biliary colic = RUQ pain
Cholecystitis = as above and fever/raised WCC
Cholangitis = as above and jaundice

44
Q

What are some common differentials of acute RUQ pain?

A

Biliary colic
Cholecystitis
Acute cholangitis
Peptic/duodenal ulcer
Acute pancreatitis
Right basal pneumonia
Ectopic pregnancy.

Surgery block (23 decks)

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