Gallstones Flashcards by Annie J

What are the commonest causes of acute abdominal pain?

· nonspecific abdominal pain
· cholelithiasis 
· renal colic
· biliary colic
· Cholecystitis
· Appendicitis
· Diverticulitis
· Infection
· Renal stones
· Pancreatitis

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What investigations can be carried out to make a diagnosis?

· Blood pressure
· Pregnancy test (to exclude possibility of ectopic pregnancy)
· FBC
· Serum electrolytes + CRP
· Creatinine + urine + general kidney function test
· ECG + serum troponin (to exclude MI)
· Abdominal X-ray
· US
· CT (not first line since most stones are radiolucent- don’t show up)
· Hepatobiliary iminodiacetic acid (HIDA) scan (cholescintigraphy -> using a radioactive tracer)

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What could sudden onset of pain be caused by?

perforated ulcer
oesophageal tear or rupture
nephrolithiasis
biliary colic
acute cholecystitis
pancreatitis
appendicitis

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What could intermittent pain be caused by?

Bowel obstruction

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What could persistent pain be caused by?

Diverticulitis

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What actions exacerbate pain caused by cholecystitis or cholelithiasis?

Eating, especially eating fatty food.

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Pain caused by what condition is exacerbated by movement?

Apendicitis

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Pain relieved by eating that worsens after a few hours is caused by?

duodenal ulcer

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What is biliary colic?

Temporary obstruction of the cystic duct/ CBD which causes colicky pain.

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What are the symptoms?

colicky pain

- vomiting

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Describe what you would see in the bloods of a person with biliary colic?

Normal WBC
Normal CRP
THERE IS NO INFLAMMATION

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What is cholecystitis?

Inflammation that is usually caused by gallstones.
Very rarely, it can be caused by poor perfusion of the gallbladder (acalulous cholecystitis by this only occurs in acutely unwell patients)

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What sign alludes to cholecystitis?

Murphy’s sign (pain on inspiration in RIGHT UPPER QUADRANT)

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Describe what you would see in the bloods of a person with cholecystitis?

Elevated WBC
High CRP
Fever
THERE IS INFLAMMATION

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What is cholangitis?

Inflammation of the biliary tree which leads to infection. THIS IS THE MOST SEVERE.

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What is the main symptom of cholangitis?

Jaundice

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Describe what you would see in the bloods of a person with cholangitis?

elevated WBC
High CRP
Elevated liver secretions (e.g. increased albumin, ALP)
fever

How are cholesterol gallstones formed?

1) Super saturation of cholesterol in bile -> it crystalises (nucleation factors involved) -> creates stones in the gall bladder.
2) Gallbladder hypomotility -> Incomplete/impaired gallbladder emptying

What are the risk factors for gallstones?

age (>40)
gender (females are more susceptible)
obesity (+ Diabetes Mellitus)
hypercholesterolaemia
Hb disorders
fertility

What are some complications of gallstones?

Mirizzi syndrome
Acute pancreatitis
Biliary obstruction
Gallstone ileus
Jaundice
Buvert’s syndrome

What is Mirizzi syndrome?

obstruction of cystic duct by gallstones

What is gallstone ileus?

Gallstone perforates through the wall of the gallbladder and hedges itself into the ileum.

What is Buvert’s syndrome?

Stone obstructs the top of the duodenum.

If person with gallstones has symptoms, what is the treatment?

Laparoscopic cholecystectomy -> removal of gall bladder

What are some complications of surgery?

GENERAL - infection - damage to nearby organs - anaesthesia risks - DVT clots - muscle inactivity due to procedure - scars from surgery - Bleeding - Post cholecystectomy syndrome SPECIFIC - Haemorrhage - Bile duct injury

How do you inform patients about procedures?

1. Find out the extent of their knowledge of their condition/ procedure. 2. Explain diagnosis and procedure 3. Give them all the treatment options (medical + non-medical) 4. Tell them the purpose of the procedure 5. Tell them the risks associated with the procedure 6. Tell them about follow up treatment

What should you check before asking them for consent?

Their capacity

What factors modulate formation of cholesterol microcrystals in supersaturated bile?

kinetic protein factors like mucin

If pigment salts are brown, that suggests...?

infections of the biliary tract

If pigment salts are black, that suggests...?

calcium bilirubinate -> haemolytic anaemia, ineffective haematopoiesis, CF

What are the symptoms of acute cholecystitis?

- Prolonged abdominal pain - associated fever - Leukocytosis

What are the drug treatments are being looked into treating these conditions?

- Somatostatin analogues (to block release of CCK and therefore bile) - Fibrates (to block rate-limiting enzyme 7-alpha-hydroxylase and cause increased cholesterol and decreased bile acid production) - Bile acid sequestrants (to prevent reabsorption of bile acids in the ileum and lead to lower cholesterol levels as the body is forced to use it as a substrate to produce new bile acids)

Once gallstones form, is the risk of developing symptomatic gallstone disease higher or lower in those with efficient bladder emptying?

HIGHER: efficient gall bladder emptying makes it more likely for the stone to end up in the biliary tree + cause symptomatic disease.

What is a combination of RUQ pain, jaundice and fever in cholangitis is known as?

Charot's triad

Describe the mechanism of cholecystitis.

1. Stone stuck in cystic duct. 2. Blocks bile from leaving the bladder. 3. This leads to inflammation of the mucosa 4. Phospholipase A secretion 5. Prostaglandins are released

Pain caused by what is usually constant?

inflammation

Pain caused by what is usually colicky?

obstruction in bowel or ureter

Is visceral pain well localised?

NO- dull and achey + spreads

Is parietal pain well localised?

YES- sharp

What does pain arising from the kidneys feel like?

It radiates from flanks to loin

What does pain arising from appendicitis feel like?

starts centrally and gradually radiates to RIF (right iliac fossa)