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Liver > Gallstones > Flashcards

Gallstones Flashcards

1
Q

What percentage of gallstones are asymtomatic?

A

90%

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2
Q

What are the “five F’s” that predispose an individual to gallstones?

A

Fasting, fat, fertile, females over forty

PREGANCY IS AN IMPORTANT FACTOR TOO

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3
Q

What are the mechanisms of risk factors for gallstone formation?

A

Increased cholesterol secretion
Impaired gallbladder emptying
Decreased bile salt secretion

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4
Q

There are three types of gallstone, what are they and give the percentage of cases they make up…

A

Mixed 80%= cholesterol with bile pigments and calcium salts
Pigmented 10%= contain calcium bilirubinate
Pure cholesterol 10%

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5
Q

What are pigmented gallstones associated strongly with?

A

Haemolytic disorders (haemolytic anaemia, malaria) they are very rare in western countries

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6
Q

What risk factors increase the chance of the gallstones becoming symptomatic?

A

Smoking and parity (the number of times a woman has carried a baby past a gestational age of 20 weeks)

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7
Q

When bile is super saturated with with cholesterol (due to high cholesterol or relative low bile salts I.e. In pregnancy) it is termed what type of bile?

A

Lithogenic bile

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8
Q

What is the name of the factors which increase crystallisation of litho genie bile?

A

Nucleation factors

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9
Q

Biliary sludge can be produced under normal conditions and is usually dissolved. What percentage of patients develop gallstones?

A

15%

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10
Q

Name the complications of gallstones that may occur?

A

Biliary colic, dyspepsia following fatty foods, cholecystitis, pancreatitis, mucocele/empeyema, obstructive jaundice, ascending cholangitis, gallstone ileus

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11
Q

What is biliary colic? What does it indicate?

A

It is a progressive build up of pain in the RUQ usually for about 2 hours. If it hasn’t passed for 6 hours then a complication of cholycystitis or pancreatitis is likely.
Pain brought on by fatty foods

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12
Q

What investigations would you do for gallstones?

A

LFTs, serum amylase, blood cultures, ultrasound, ERCP, MRCP

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13
Q

What are the features of an obstructive picture on LFTs?

A

Raised: bilirubin, ALP, ALT and AST)

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14
Q

Why would you do a serum amylase test?

A

To rule out pancreatitis

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15
Q

How sensitive is USS?

A

90%

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16
Q

Where can the pain from biliary colic be referred to?

A

The right shoulder

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17
Q

What causes acute cholecystitis?

A

A stone/sludge that has become embedded in Hartmann’s pouch of the gallbladder with bacterial infection (often the gram -ve e. Coli gut flora)

18
Q

What are the symptoms of acute cholecystitis? (Similar to biliary colic but with an inflammatory component)

A

Continuous RUQ/epigastric pain, referred pain to the right shoulder, N+V, fever, local peritonism, GB mass, tachycardia

19
Q

What sign may indicate acute cholecystitis? When is it positive?

A

Murphy’s sign - two fingers pressed on the RUQ, inhale causes pain and pain dissipates on exhalation. It is positive if there is no pain on the left side when repeated on the LUQ

20
Q

What does Chronic cholecystitis lead to?

A

Fibrosis and enlarged gallbladder with atrophied mucosa

21
Q

What is the name of the rare form of cholecystitis that occurs without gallstones?

A

Acalculous cholecystitis (caused by burns, sepsis and diabetes)

22
Q

What investigations would you do for acute cholecystitis?

A

FBC (raised WCC), USS, HIDA cholescintigraphy, AXR

23
Q

What are the features of acute cholecystitis on an USS?

A

Thick walled, shrunken, stones present, biliary sludge

24
Q

What is the treatment for acute cholecystitis?

A

Nil by mouth, IV cefuroxime, IV pain relief, laparoscopic cholecystectomy (or open if perforated)

25
Q

A ‘porcelain GB’ if picked up on the AXR is associated with a 15% in?

A

Cancer

26
Q

GB cancer is rare however what percentage of cancer of the GB is associated with gallstones?

A

95%

27
Q

Prevalence of gallstones in over 40s?

A

8%

28
Q

What is a mucocele and how does it occur?

A

A tender area of mucus build up that can become infected to form an abscess (empyema). It occurs when a stone impacts on the Hartmann’s punch and continued mucus secretion builds up behind it

29
Q

What is Mirrizi’s syndrome?

A

An uncommon complication where a stone impacts on cystic duct and causes swelling that can cause obstructive jaundice by compressing the CBD

30
Q

What specific complications result from the stones being in the CBD?

A

Obstructive jaundice, ascending cholangitis, gallstone pancreatitis

31
Q

What are the features of obstructive jaundice?

A

Jaundice, dark urine (due to conjugated bilirubin dissolved in it) and pale stools

32
Q

What is ascending cholangitis?

A

Infection of the bile duct which can spread up into the intra hepatic ducts which may cause liver abscess or scepticemia (it is life threatening)

33
Q

What triad is associated with ascending cholangitis and what does it include?

A

Charcot’s triad

Rigors (fever and chills), obstructive jaundice and RUQ pain (referred to right shoulder)

34
Q

What is the treatment for ascending cholangitis?

A

ERCP, cefuroxime and metronidazole

35
Q

What happens when a gallstone impacts on the pancreatic duct?

A

Gallstone pancreatitis (see relevant flash cards)

36
Q

Gallstone ileus is a small bowel obstruction (ileocecal valve esp) caused by a stone, how does this occur?

A

A stone erodes through the gallbladder wall into the small duodenum via a cholecystoenteric fistula

37
Q

What investigation would you do and what would you see?

A

AXR showing air in the biliary tree (pneumobillia)

38
Q

Who does gallstone ileus occur in usually?

A

Elderly and is still rare

39
Q

List the 3 main complications of cholecystectomy

A

Bile duct injury, retained stones, bile ducts structure

Other = haemorrhage, infection, hernia

40
Q

What operations can be done to remove the gallbladder and cystic duct?

A

Laparoscopic, one stage open, two stage open

Liver (8 decks)

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