Gallstones Flashcards
How does biliary colic (symptomatic gallstones) present?
-Pain in the right upper quadrant and epigastrium that extends to the tip of the scapula.
Severe, constant and last from 30 minutes to 24 hours.
Can start after eating
-Nausea and vomiting.
-Pain relieves once the stone is disimpacted
How does acute cholecystitis present?
- Pain in the RUQ/epigastrium: which is unremitting
- Lasts for days.
- Nausea/vomiting
- Fever/chills
-History of previous biliary colic
What confirms the dx of acute cholecystitis?
- Signs of local inflammation= Positive murphy’s sign + RUQ tenderness
What confirms the dx of acute cholecystitis?
- Signs of local inflammation= Positive murphy’s sign + RUQ tenderness.
- Signs of systemic inflammation= Fever+ High WCC + High CRP
- Ultrasound features
What are the diagnostic US features of acute cholecystitis?
- Positive sonographic murphys sign
- Gallbladder wall thickening ( greater than 4 mm)
- Peri-cholecystic fluid
- Distended gallbladder
- Conformation of gallstones in the gallbladder
How do you grade cholecystitis?
1.Mild
- Moderate (if any of the following present)
- High WCC above 18 000
- Greater than 72 hours
- Tender mass in RUQ
- Gangrenous or emphysematous gallbladder
- Abscess (Pericholecystic or hepatic) - Severe
- Any organ dysfunction (resp, renal, neuro, cvs)
What id the mx of acute cholecystitis?
- Initial Mx for all
- Admission
- Fluid Resus
- Analgesia
- IV antibiotics (cover gram negative and anaerobic organisms)
*Mild and moderate cholecystitis = Laparoscopic Cholecystectomy, ideally 4-7 days of onset of sx.
Resource strained settings= if pt responds to initial management then elevtice lap cholecystectomy.
If pts dont respond to initial mx and laporoscopic cholecystectomy is not feasible due to aneas risks, percutaneous cholecystostomy is done.
- For severe choecystitis:
- Urgent percutaneous cholecystostomy then
- Lap Cholecystectomy once the pt has systematicaaly improved
Complications of acute cholecystitis:
- Emphysematous gallbladder
- Empyema of gallbladder
- Necrotic gallbladder
- Perforation of gallbladder
Choledocholithiasis presenting sx:
- same as biliary colic but may be prolonged.
- Jaundice
What investigations must be done for suspected choledocholithiasis?
- ERCP (both dx and therapeutic)
- MRCP
- Laporoscopic intraoperative cholangiogram
What are the predictors of choledocholithiasis?
- Moderate= Abnormal GGT and ALP, Age greater than 55, Gallstone pancreatitis.
- Strong= Total Bilirubin of 30-68, Common bile duct greater than 6 mm on US.
- Very strong=Bilirubin greater than 68, CBD stone seen on US, Cholangitis
Mx options of cholodocholithiasis:
- ERCP
- Lap CBD exploration
- Open CBD exploration
Complications of ERCP:
- Pancreatitis
- Bleeding
- Infection (colonization of biliary tree, cholangitis)
- Perforation (oesophagus, stomach, duodenum, CBD)
- Sedation related complications.
