Gallstones Flashcards
What is cholelithiasis?
Gallstones
Formed from constituents of the bile:
cholesterol
calcium salts (phosphates, carbonates)
bilirubin (calcium bilirubinate)
Two main types
Cholesterol stones
Pigment stones
What decreases bile acid causing gall stones?
Oestrogens
Excessive gut loss (terminal ileal disease eg Crohn’s)
Bile salts have been used to dissolve stones
What causes pigmented gallstones?
Calcium bilirubinate
biliary infections
Abnormal red cell breakdown (haemolytic anaemia)
CAB
what can gallstones cause?
“Chronic cholecystitis”
Obstruction
Predisposition to Carcinoma of the Gall Bladder and Biliary tract
Small minority of cases
What is chronic cholecystitis?
Longstanding irritation of gall bladder
Thickening of gall bladder wall
Muscle hypertrophy
Low grade chronic inflammation
Fibrosis
Diverticula - misplacement of mucosa into wall
“Rokitansky-Aschoff sinuses”
Motility disorders
Dyspepsia
Right upper quadrant pain, often related to fatty foods
What sinuses are mostly effected by gallstones?
Rokitansky-Aschoff sinuses
Signs of cystic duct obstruction?
Acute (on chronic) cholecystitis
Secondary infection by bowel bacteria
Purulent bile
Empyema
Septicaemia
Perforation
Tell me about acalculous cholecystitis?
5-10% of all acute cholecystitis
Usually a complication of some other critical illness
Sepsis, trauma, burns
Total parenteral nutrition
Due to increased bile viscosity and ischaemia
Poor prognosis
Common duct stones?
Biliary colic
Obstructive jaundice
-Dilated bile ducts (ultrasound)
-Enlarged green stained liver
Causes of obstructive jaundice?
Extrahepatic bile duct obstruction
Pale stools, dark urine
Conjugated hyperbilirubinaemia
Raised alkaline phosphatase
Mildly raised transaminases
Malabsorption of fat and vitamin K
Itching
Ascending cholangitis
Septicaemia
Liver abscess
Benign bile duct strictures
Instrumentation / surgery
Sclerosing cholangitis
HIV cholangiopathy (CMV, cryptosporidiosis)
Parasites (Clonorchis, Ascaris, Fasciola)
Carcinoma of
the bile duct
The duodenum (ampulla of Vater)
The pancreas
Compression of bile ducts by extrinsic masses
Tell me about carcinoma of the gall bladder?
Adenocarcinoma
Preceded by dysplasia
Rare
Elderly women
90% have gall stones
Local structures (especially liver) usually invaded at presentation
Poor prognosis
Median survival 6 months
Tell me about carcinoma of the bile duct?
Uncommon in West (but increasing)
Commoner in Orient
Associated with
Gall stones
Clonorchis sinensis
Inflammatory bowel disease (sclerosing cholangitis)
Congenital abnormalities (eg choledochal cyst)
Often multifocal
Painless obstructive jaundice, cholangitis
Poor prognosis
How would you examine the gall bladder and pancreas?
Endoscopic retrograde cholangio-pancreatography
Tell me about pancreatitis?
Common, incidence 0.1-1/1000 in West
Acute inflammation, haemorrhage and necrosis of pancreas
Liberation of digestive enzymes
Raised serum amylase
Fat necrosis
Secondary bacterial infection
May lead to pancreatic pseudocyst
Conversion of necrotic pancreas into a cyst filled with fluid and necrotic debris
Severe abdominal pain
Jaundice if CBD obstructed
Peritonitis - chemical, bacterial
Shock
Septicaemia
Adult respiratory distress syndrome
GI haemorrhage
Acute renal failure
10-15% mortality
Causes of acute pancreatitis?
Alcohol
Gall stones
Iatrogenic
Abdominal trauma
Drugs
azathioprine, antibiotics, diuretics, NSAIDs
Infections
Mumps, EBV
Hereditary
Autosomal dominant
Hypercalcaemia
Tumours (obstruction)
Congenital anomalies
Hypothermia
Ischaemia
Idiopathic