Gallstone diseases

Question 1

Describe the basic anatomy of the biliary system

Answer 1

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.

Question 2

What is the function of the gallbladder?

Answer 2

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

Question 3

What is bile made up of?

Answer 3

Cholesterol, bile salts and bile pigements (bilirubin)

Question 4

What is the basic composition of gallstones?

Answer 4

Hardened bile deposits

Question 5

What causes gallstone formation?

Answer 5

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

Question 6

What is the prevalence of gallstones?

Answer 6

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

Question 7

What are the three different types of gallstones?

Answer 7

Pigment stones
Cholesterol stones
Mixed stones

Question 8

What are pigment stones in the gall bladder?

Answer 8

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

Question 9

What are cholesterol stones in the gallbladder?

Answer 9

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

Question 10

What are mixed stone, gallstones?

Answer 10

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.

Question 11

What are the three main gallstone conditions?

Answer 11

Biliary colic
Cholecystitis
Acute cholangitis

Question 12

What is biliary colic?

Answer 12

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

Question 13

What are the symptoms of biliary colic?

Answer 13

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

Question 14

What are the treatments available for biliary colic?

Answer 14

Analgesia
+/- elective cholecystectomy

Question 15

What is a cholecystecomy?

Answer 15

Typically is a laparoscopic removal of the gall bladder.

Question 16

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

Answer 16

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?

Question 17

What is cholecystitis?

Answer 17

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

Question 18

What are the main risk factors for acute cholecystitis?

Answer 18

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

Question 19

What are the symptoms of cholecystitis?

Answer 19

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%

Question 20

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

Answer 20

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.

Question 21

What is CCK?

Answer 21

A peptic hormone linked to the gastrointestinal system

Question 22

What are the different effects of CCK?

Answer 22

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.

Question 23

How is Murphys sign relevant to cholecystitis?

Answer 23

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.

Question 24

What investigations should be done for a suspected cholecystitis?

Answer 24

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

Question 25

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

Answer 25

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

Question 26

What is the definitive care for acute cholecystitis?

Answer 26

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

Question 27

What are the indications for an emergency cholecystectomy?

Answer 27

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

Question 28

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

Answer 28

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.