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Abdo Surgery > Gallstones > Flashcards

Gallstones Flashcards

1
Q

Who is most likely to get gallstones

A

Fair

Fat

Fertile

Female

40

Family history

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2
Q

What are the common varieties of gallstones

A

Cholesterol stones - 20%

Bile pigment stones - 5% (black pigment stones)

Mixed stones - 75% (brown pigment stones)

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3
Q

What may cholesterol stones be associated with

A

High cholesterol

Pregnancy

Diabetes

Oral contraceptive pill

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4
Q

What is the pathophysiology of a cholesterol stone

A

Bile salts and phospholipids hold insoluble cholesterol in suspension

Decrease of either can lead to cholesterol gallstones

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5
Q

What are bile pigment stones

A

Small, black, irregular, multiple, gritty and fragile stones

Occur in excess of circulating bile pigment (eg. haemolytic anaemia)

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6
Q

What are mixed stones

A

A mixture of cholesterol, bile pigments and calcium salts

Cholesterol is the predominant constituent

They are multiple and faceted

They originate because of precipitation of cholesterol

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7
Q

What are some predisposing factors for gallstones

A

Excess mucus production by the gallbladder

Infection of the biliary tract

Metabolic factors

Stasis (eg. in pregnancy)

Ileal dysfunction (prevents reabsorption of bile)

Obesity

Chronic liver disease

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8
Q

What are some of the pathological effects of gallstones

A

Asymptomatic - 20%

Obstruction of the gallbladder

Movement of a stone into the common bile duct

Ulceration of a stone through the wall of the gallbladder - gallstones may erode into the duodenum or colon. May cause gallstone ileus

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9
Q

How can gallstones cause obstruction of the gallbladder

A

A gallstone may become impacted in Hartmann’s pouch, causing an obstruction to the exit of the gallbladder

Tihs causes cholecystitis

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10
Q

What is gallstone ileus

A

Impaction of a stone in the distal ileum resulting in intestinal obstruction

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11
Q

In gallstone ileus, where in the GI tract does the gallstone normally become lodged

A

At the level of the ileocaecal valve OR

at the site of Meckel’s diverticulum

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12
Q

Where is Meckel’s diverticulum

A

2 feet proximal to the ileocaecal valve

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13
Q

How can gallstones present

A

Biliary colic

Acute cholecystitis

Chronic cholecystitis

Gallstone pancreatitis

Obstructive jaundice

Acute cholangitis

Gallstone ileus

Empyema and emphysema of the gallbladder

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14
Q

What is biliary colic

A

It probably results from distension of the gallbladder outlet or duct system when a stone becomes impacted

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15
Q

What are the features of biliary colic

A

Colicky right hypochondrial/epigastric pain

Pain radiating to lower pole of right scapula

Restless and rolling in agony

Sweaty, nauseous and vomiting

*The episode may resolve when the stone is passed along the duct or falls back into the gallbladder

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16
Q

What are some differentials for biliary colic

A

Renal colic

Intestinal obstruction

Angina

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17
Q

What is acute cholecystitis

A

Inflammation of the gallbladder

In 95% cases it is secondary to obstruction of the cystic duct by gallstones

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18
Q

What are the typical clinical features of acute cholecystitis

A

RUQ pain - becoming more severe, constant and localised after 1/2 days

Fever

Rigors

History of previous dyspepsia, fat intolerance, or biliary colic

On examination

  • Guarding in the RUQ
  • Murphy’s sign
  • Palpable mass - if gallbladder is distended
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19
Q

What is Murphy’s sign

A

Patient catches breath on inspiration while the right hypochondrium is deeply palpated (specifically the approximate location of the gallbladder).

Due to downward movement of the inflamed gallbladder onto the examining hand during inspiration

Does not occur on deep palpation of the left hypochondrium

20
Q

Where is the approximate location of the gallbladder on surface anatomy

A

Below the costal margin on the right side at the mid-clavicular line

21
Q

What are some complications of acute cholecytitis

A

Empyema of gallbladder

Perforation of the gallbladder causing peritonitis

Obstructive jaundice

22
Q

What are some causes of acalculous acute cholecystitis

(inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction)

A

If a single causative stone has passed

Typhoid fever

In critically ill individuals

*5% cases

23
Q

What are some differentials for acute cholecystitis

A

Perforated duodenal ulcer

Acute pancreatitis

Right-sided basal pneumonia

Acute appendicitis

24
Q

What is chronic cholecystitis

A

Almost always associated with gallstones that repeatedly inflame the gallbladder

This results in fibrosis and thickening of the entire gallbladder wall

25
Q

How does a patient with chronic cholecystitis present

A

Longstanding symptoms of dyspepsia with episodes of cholecystitis

26
Q

What are some differentials for chronic cholecystitis

A

Peptic ulceration

Hiatus hernia

Angina

27
Q

What is gallstone pancreatitis

A

Transient blocking of the ampulla of Vater by passing stones can trigger acute pancreatitis

28
Q

What is Courvoisier’s law

A

In the presence of a large non-tender gallbladder that is associated with jaundice, the cause is unlikely to be gallstones

29
Q

What is acute cholangitis

A

Due to infection of the bile in the biliary tree

It develops in the presence of bile duct obstruction and biliary infection

Charcot’s triad is present

It should also be suspected in any patient with biliary obstruction who develops septicaemia

30
Q

What is Charcot’s triad

A

RUQ pain

Fever

Jaundice

31
Q

What factors predispose to acute cholangitis

A

Stones in the common bile duct

Biliary stricture

Post-biliary reconstructive procedures

Post-bile duct instrumentation (eg. ERCP)

32
Q

How does a patient with gallstone ileus present

A

History of RUQ pain

Acute small-bowel obstruction

33
Q

How do you treat a patient with a gallstone ileus

A

Resuscitation

Nasogastric decompression

Urgent laparotomy

  • Gallstone should be milked back up the terminal ileum to a healthy bit of bowel and then removed

Definitive treatment of the fistula should be left until the acute attack has settled

34
Q

What is empyema of the gallbladder

A

Severe form of acute cholecystitis

Occurs mainly in elderly

Pus in the gallbladder

Patients are very septic

Early surgery prevents perforation

35
Q

What is emphysematous cholecystitis

A

Presents in elderly or immunocompromised

As a result of gangrenous gallbladder infected with gas forming bacteria

Urgent surgery is required

36
Q

What bacteria causes emphysematous cholecystitis

A

Clostridium perfringens

37
Q

What are the mainstays for diagnosis of gallbladder disease

A

US

LFTs

MRCP/ERCP

38
Q

How do you manage acute cholecystitis

A

Non-surgical:

  • Admission to hospital
  • Pain relief with opiates
  • IV fluids
  • Broad spectrum antibiotics

Surgical:

  • Elective cholecystectomy - either during admission or 6 weeks after discharge
39
Q

Why is cholecystectomy receommended after an attack of cholecystitis

A

High risk of recurrent attacks

High risk of life threatening complications in future attacks

  • Perforation of the gallbladder
  • Pancreatitis
  • Obstructive jaundice
40
Q

What is the non-surgical management of gallstones

A

Low fat diet

Oral bile salts (eg. chenodeoxycholic acid) used to dissolve small, non-calcified stones in patients unfit for surgery

41
Q

What are the disadvantages to non-surgical management of gallstones

A

Prolonged treatment for months

Attacks of biliary colic as fragments of stone are passed

Recurrence (common)

42
Q

What incision is used for an open cholecystectomy

A

Kocher’s - right subcostal

43
Q

What are some complications of a cholecystectomy

A

Haemorrhage from slipped tie or from gallbladder bed

Biliary leak

Biliary stricture from damage to biliary tree

44
Q

What are some contraindications to laparoscopic cholecystectomy

A

Jaundice

Cirrhosis

Previous upper abdo surgery

Surgeon not familiar with equipment or technique

Acute cholecystitis

Morbid obesity

Pregnancy

45
Q

In which cases is ERCP less likely to be successful as a therapeutic option

A

Aberrant diverticulum

Periampullary diverticulum

Prior upper GI surgery

Difficult stones

  • Those that are over 15mm
  • Intrahepatic
  • Impacted
  • Multiple

Stricture associated with the stone

Abdo Surgery (14 decks)

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