Gallstones

Question 1

cholelithiasis?

Answer 1

gallstones

Question 2

RF for gallstones?

Answer 2

Female
Fat 
Forty 
Fair 
Fertile

Question 3

what % are asymptomatic?

Answer 3

90%

Question 4

RF for symptomatic?

Answer 4

Smoking

Question 5

Pathophysiology

what is released from small intestine to help absorb high fat foods?

this stimulates gallbladder to release?

effect?

Answer 5

cholecystekinin

bile

to emulsify fats so they are easier to absorb

Question 6

can gallstones be seen on Xray?

Answer 6

NO do USS instead

Question 7

classic location of gallstone pain?

after a meal where can pain radiate to?

Answer 7

mid-epigastric region –> colciky RUQ pain

can radiate to scapula and shoulder after a meal

Question 8

when is pain worst?

Answer 8

after a fatty meal when cholecystekinin is highest and gallbladder is maximally contracted

Question 9

BILIARY COLIC

• recurrent episodes of RUQ pain lasting less than?
• pain occurs when?
• other symptoms?
• Dx?
• Tx?

Answer 9

• 6hours
• after a meal or lying flat (stone can get lodged in cystic duct)
• nausea and vomiting
• USS
• NBM, analgesia + rehydrate
• laparoscopic cholecystectomy is gold standard but not urgent

Question 10

ACUTE CHOLECYSTITIS

• pain lasting longer than?
• RUQ pain plus?
• inflam markers?
• change in LFTs?
• what sign will you find on examination?
• jaundice?
• Dx?
• Tx?
• if perforated - what Tx?

Answer 10

• > 12 hours
• fever
• raised WCC, CRP,
• LFTs normal unless Common Bile Duct obstruction occurs or cholangitis
• murphy’s sign
• NO jaundice unless CBD obstruction or cholangitis
• USS
• Tx: NBM, analgesia, reydrate
  IV Abx (cefuroxime)
  cholecystectomy (aim within 7 days)
• if perforated - open surgery and leave drain for pus removal

Question 11

ASCENDING CHOLANGITIS

• Pathophysiology?
• typical bacteria?
• RUQ pain + fever plus?
• name of triad?
• if bacteria get into bloodstream and septic - name of pentad?
• Dx?
• Tx?

Answer 11

• In cholecystitis and biliary colic – still bile able to flow down from hepatic duct to wash out bacteria travelling up from small intestine; however, as all bile flow is blocked – bacteria (e.coli – most common) can colonise biliary system. High pressure of stagnant bile can weaken bile duct muscle layer and let bacteria leak into bloodstream (septic).
• e-coli

RUQ pain + fever/rigors + jaundice

• charcot’s triad
• Raynaud’s (hypotension + confusion)
• USS
• NBM, reydrate, analgesia
• ERCP (Tx of choice as it is diagnostic and therapeutic), if severe and gallstones are main problem can do cholecystectomy after ERCP

Question 12

Common complications post cholecystectomy:

• present within a few days?
• 2 weeks post surgery?
• after any laparoscopic surgery?

Answer 12

• common bile duct injury
• common bile duct stones (may still be stones in duct higher up even if gallbladder is removed - resulting in pain and jaundice + ascending cholangitis
• surgical emphysema (air can outline pectoralis major muscle giving way to ginkgo leaf sign