Gallstones Flashcards
What are the 3 different types of Gallstones?
Cholesterol stones - Large, often solitary
Pigmented stones - Small, gritty
Mixed stones - Multiple, cholesterol main component
What are the risk factors for Cholesterol gallstones?
Obesity, high fat diet Female Increasing age Pregnancy OCP Loss of terminal ileum (↓bile salts)
How do Cholesterol gallstones form?
Due to Admirand’s Trangle
- ↓ bile salts
- ↓ lecithin
- ↑ cholesterol
What are Pigmented gallstones formed of?
Calcium bilirubinate
Associated with heamolysis
What are some of the causes of Gallstones forming?
Gall bladder hypomobility (Causes stasis) eg TPN, fasting, OCP, pregnancy
Biliary sepsis
Admirand’s triangle (↓bile salts, ↓lecithin, ↑cholesterol)
What are the complications of Gallstones?
Gallbladder - Biliary colic, Cholecystitis (Acute/Chronic), Mucocele, Carcinoma
CBD - Obstructive jaundice, Pancreatitis, Cholangitis
Gut - Gallstone ileus (Small bowel obstruction due to gallstones)
What causes Biliary colic?
Gallbladder spasms against stone impacted in neck (Hartmann’s pouch)
Can be in CBD, but less common
What are the differentials for Biliary colic?
Cholangitis
Cholecystitis
Pancreatitis
Bowel perforation
Define Acute Cholecystitis
Inflammation of Gallbladder usually due to a stone becoming stuck within Hartmann’s pouch (but can be due to surgery or sepsis) causes infection
How does Acute Cholecystitis present?
RUQ pain - Continuous + severe. Radiates to R scapula + epigastrium
Vomiting
Fever
Raised WCC
What is Murphy’s sign?
Place 2 fingers over the Gallbladderand ask pt. to breath in
Causes pain + pt attempts to catch breath
What are the complications of Acute Cholecystitis?
Gangrene
Perforation
Chronic Cholecystitis
Empyema
What investigations can be done for a patient with suspected Acute Cholecystitis?
Bloods -WCC, U+Es, LFTs, CRP, Clotting, G+S
Erect CXR - check for perforation
US - Thickened gallbladder, dilated ducts (>6mm), shadow from stones
Can do MRCP if unsure after US
What is the management of Acute Cholecystitis?
Conservative - NBM, Fluids, Analgesia, cefuroxime and metronidazole
Surgery - Elective 6-12 weeks after, if
What is the treatment if an empyema develops in Acute Cholecystitis?
Pt will have high fever + RUQ mass
Cholecystostomy (Percutaneous drainage of pus)
What are the symptoms of Chronic Cholecystitis?
Dyspepsia Vague upper abdominal discomfort Distension Bloating Nausea Burping *Symptoms worsened by fatty foods due to cholecystokinin release from gallbladder*
What investigations can be done in a patient with suspected Chronic Cholecystitis?
AXR - Show porcelain gallbladder
US - Fibrotic, shrunken gallbladder with stones
MRCP
What is the management of Chronic Cholecystitis?
Medical - Bile salts (Not very effective)
Surgical - Elective cholecystectomy, ERCP if distended bile ducts/stones on US
Define Cholangitis
Infection of the bile duct usually caused by bacteria ascending from the duodenum. It tends to happen when the bile duct is already partially blocked by gallstones
How does Cholangitis present?
RUQ pain
Fever, raised WCC
Jaundice
(Charcot’s triad)
What investigations can be done in a patient with suspected Cholangitis?
Bloods
US
MRCP
What is the treatment for Cholangitis?
Fluids
Ciprofloxacin + Metronidazole
ERCP to unblock bile duct
Cholecystectomy once settled
What are the indications for surgery in pts with Gallstones?
Symptomatic Blockage of bile ducts Inflammation of Gallbladder Large gallstones (>2cm) Non functioning Gallbladder
What is Primary sclerosing cholangitis?
Inflammatory fibrosis of the bile ducts, suspected to be autoimmune. Effects the Gallbladder and Liver.
How does Primary sclerosing cholangitis present?
Asymptomatic - LFTs derranged, hepatomegaly Jaundice Puritis RUQ pain Fatigue Wt loss Night sweats Fever
What investigations can be done in a patient with suspected Primary sclerosing cholangitis?
Bloods - LFTs, GGT, Increase in immunoglobulin
MRCP/ERCP
US
What is the management of Primary sclerosing cholangitis?
Supportive
Stents/balloons to hold open any strictures which may be causing Cholangitis
Slowly progresses to liver cirrohsis/failure - need transpant
