Gallstones Flashcards
normal capacity of gallbladder
50ml
Bile is made by
hepatocytes against concentration gradient under pressure
what does gall bladder do to bile
increases concentraation 5-10%
through active uptake of electrolytes from the bile causing water to also flow out of the bile (osmotic gradient)
bilirubin is generated from sequential catalytic degradation of haem mediated by two groups of enzymes:
haem oxygenate
biliverdin reductase
bilirubin is poorly soluble in
water
how does bilirubin stay in solution in plasma
by binding albumin
how does albumin binding help bilirubin
keeps it in the vascular space
prevents it from depositing into extra hepatic tissues such as the brain or kidney (toxic)
transports bilirubin into the sinusoidal surface of the hepatocyte, where the pigment dissociates from albumin and enters the hepatocyte
before excreted in bile and urine, bilirubin must be
conjugated in the liver to make it more water soluble
urine symptoms of uncongugated hyperbilirubinaemia
not water soluble, therefore doesn’t appear in urine
urine symptoms of conjugated hyperbilirubinaemia
can pass into urine as urobilinogen, causing urine to become darker
breakdown of haem
haem is broken down by
haem oxygenase
into biliverdin
biliverdin is broken down by
biliverdin reductase
into bilirubin
bile acids/salts are made up of
chenodeoxycholic acid, cholic acid
secondary bile acids, deoxycholic acid and lithocholic acid
some qualities of bile acids/salts
forms micelles with fat
allow digestion with lipase
recycled in enterohepatic circulation
lethicin helps dissolve
cholesterol
things that cause predisposition to gallstones
western societies: cholesterol stones F>M
non western societies: brown pigment stones, chronic infection w biliary flukes
blood disorders: black pigment stones
what predisposes to black pigment stones
form in conditions of excess unconjugated bilirubin which may be caused by haemolysis in blood disorders like thalassaemia, spherocytosis, sickle cell
or in conditions like cirrhosis and splenomegaly.
which type of gallstones do people in western societies typically get
cholesterol
nature of biliary colic pain
post prandial
persistant
epigastric (visceral) pain
severe
cholecystitis
the primary insult is the impaction of the stone
combined mechanical, chemical and infectious process
bile culture is positive in 75% of cases
possible complications of cholecystitis
gangrene
perforation
empyema
mucocoele
gas producing infection
chronic cholecystitis
gangrene in gall bladder
GB wall dies as inflammation causes thrombosis and perfusion falls
empyema in gall bladder
pus is trapped in the GB
mucocoele in gall bladder
sterile mucous trapped in GB
chronic cholecystitis
fibrosis
fistulation
formation of large stone called mirizzi syndrome
choledocholithiasis
common bile duct stones
complications of choledocholithiasis
obstructive jaundice
cholangitis
pancreatitis
jaundice is caused by
impaired bilirubin excretion
raised conjugated bilirubin level
becomes present in urine (normal urobilinogen)
becomes absent in stool (normal stercobilinogen)
jaundice leads to
bile salts cause itch
steatorrhoea from failure to emulsify fats
vit K malabsorption causes coagulopathy
eventually liver and kidney failure
jaundice is caused by raised levels of
serum conjugated bilirubin level
charcots triad is used to indicate the presence of
acute cholangitis
the symptoms of chariots triad
jaundice, fevers (usually with rigors), RUQ pain
what are the symptoms of reynold’s pentad
jaundice, fevers (usually with rigors), RUQ pain, confusion, shock
basically charcots triad but with the mental status changes of confusion and shock
Reynolds pentad is indicative of
acute cholangitis
how does the location of the stone affect the diagnosis
GB cancer is increased risk in
First Nations Americans, Pakistan, India, Maori, Indigenous Australians
risk increases x4 in people with stones
prognosis for GB cancer
rarely curable
required radical resection as it infiltrates deeply
GB cancer may present as
may present as a very early polyp, a mass on imaging, or most commonly with advanced disease, jaundice from hilarity infiltration and metastases
cholangiogram may help you visualise
stones and blockage
complications of cholecystectomy
bile duct injury
death
bike leak
bleeding
retained stones
infection in ports
lap injury to bowel
pneumoperitoneum
general post op complications eg. DVT, PE, pneumonia
what could be done instead of cholecystectomy?
ERCP
cholecystostomy
ERCP
endoscopic retrograde cholangiopancreatography
camera to duodenum, wire up ampulla into the bile duct, removes stone and places stent
problems with ERCP
have to cut ampullarf muscle, allows duodenal reflux into CBD, can cause chronic inflammation, cancer risk is low but isn’t 0
cholecystostomy
needle into GB under USS guidance to decompress bile/pus
post cholecystectomy syndrome
altered fat absorption
diarrhoea with high fat content meals
rare in gallstone pathology
common if missed original diagnosis
