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Gallstones Flashcards

1
Q

What are gallstones?

A

Gallstones are small stones that form in the gallbladder

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2
Q

What happens in most cases of gallstones?

A

They don’t cause symptoms, and can remain untreated

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3
Q

What can happen if a gallstone becomes trapped in a duct?

A

It can cause biliary colic and other complications

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4
Q

What do gallstones contain?

A
  • Cholesterol
  • Bile pigments
  • Phospholipids
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5
Q

What happens if the concentrations of different constituents of gallstones vary?

A

Different stones can form

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6
Q

What is the prevalence of gallstones in those over 40 years?

A

8%

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7
Q

What are the risk factors for the gallstones becoming symptomatic?

A
  • Smoking
  • Parity
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8
Q

What are bile pigments?

A

Products of haemoglobin metabolism

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9
Q

Where is bile stored?

A

In the gallbladder

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10
Q

What happens to bile on gallbladder stimulation?

A

It passes into the duodenum

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11
Q

When do gallstones develop?

A

When bile contains too much cholesterol and not enough bile salts

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12
Q

What other factors are important in gallstone formation?

A
  • How ofetn and well the gallbladder contracts
  • Presence of proteins in liver and bile that either promote or inhibit cholesterol crystallisation into gallstones
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13
Q

How is how often and well the gallbladder contracts important in the development of gallstones?

A

Infrequent or incomplete emptying can cause the bile to become over-concentrated and lead to gallstone formation

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14
Q

How is oestrogen involved in gallstones?

A

It has been found to increase cholesterol levels in bile and decrease gallbladder movement, resulting in gallstone formation

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15
Q

What are the types of gallstones?

A
  • Pigment stones
  • Cholesterol stones
  • Mixed stones
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16
Q

What are pigment stones?

A

Small, friable stones

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17
Q

What causes pigment stones?

A

Haemolysis

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18
Q

What are cholesterol stones?

A

Large, often solitary stones

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19
Q

What are the risk factors cholesterol stones?

A
  • Female gender
  • Age
  • Obesity
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20
Q
  • Fat
  • Female
  • Fertile
  • Forty
  • Family history
  • Pregnancy and oral contraceptives
  • Haemolytic anaemia
  • Malabsorption, e.g. ileal resection, Crohn’s disease
A
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21
Q

Why do pregnancy and oral contraceptives increase the risk of gallstones?

A

Because oestrogen causes more cholesterol to be secreted into bile

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22
Q

How are most gallstones discovered?

A

Most are asymptomatic, and picked up incidentally on ultrasound scans, most commonly a trans-abdominal ultrasound

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23
Q

What investigations are done in gallstones?

A
  • Liver function tests
  • Ultrasound
  • Consider MRCP
  • Blood tests
  • Urinalysis
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24
Q

Who should LFTs and ultrasound be offered to?

A

All people with suspected gallstone disease

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25
Q

When should MRCP be considered in gallstones?

A

If ultrasound didn’t detect common bile duct stones, but the bile duct is dilated or LFTs are abnormal

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26
Q

What should urinalysis in gallstones include if female?

A

Pregnancy test

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27
Q

Why is urinalysis done in the investigation of gallstones?

A

To exclude any renal or tubo-ovarian pathology

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28
Q

What is the first line imaging in gallstones?

A

Trans-abdominal ultrasound

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29
Q

Why is transabdominal ultrasound first line in investigation of gallstones?

A

Because it is one of the most sensitive modalities for visualising gallstone disease

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30
Q

What might trans-abdominal ultrasound show in gallstones?

A
  • Presence of gallstones or sludge
  • Gallbladder wall thickening
  • Bile duct dilation
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31
Q

What does gallbladder wall thickening indicate?

A

That inflammation is likely

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32
Q

What does bile duct dilation indicate?

A

A possible stone or stricture in the distal bile ducts

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33
Q

What blood tests are done in the investigation of gallstones?

A
  • FBC and CRP
  • U&Es
  • LFTs
  • Amylase
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34
Q

What might FBC and CRP show in gallstones?

A

May show evidence of an inflammatory resposne

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35
Q

When might gallstones cause an inflammatory response?

A

In biliary pathology such as cholecystitis, cholangitis, and pancreatitis

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36
Q

Why should U&Es be done in gallstones?

A

Assess for any dehydration secondary to reduced oral fluid intake

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37
Q

What may be shown on LFTs in gallstones?

A

Biliary colic and acute cholecystitis likely to show raised ALP, indicating ductal occulsion, yet other parameters should remain within normal ranges

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38
Q

Why should amylase be checked in suspected gallstones?

A

Check for pancreatitis

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39
Q

When is no treatment required for gallstones?

A

When a person has asymptomatic gallstones found in a normal gallbladder

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40
Q

When should a person with asymptomatic gallstones be treated?

A

If they are in the common bile duct

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41
Q

Why should a person with asymptomatic gallstones in the common bile duct be treated?

A

Because that person is at high risk of developing serious complications such as cholangitis or pancreatitis

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42
Q

How should a person with asymptomatic gallstones in the common bile duct be managed?

A

Same as a person with symptomatic gallstones

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43
Q

What are the symptomatic presentations of gallstones?

A
  • Biliary colic
  • Acute cholecystitis
  • Chronic cholecystitis
  • Obstructive jaundice
  • Cholangitis
  • Gallstone ileus
  • Pancreatitis
  • Mucocoele/empyema
  • Mirizzi’s syndrome
  • Gallbladder necrosis
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44
Q

What is biliary colic?

A

When gallstones become symptomatic with cystic duct or common bile duct obstruction

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45
Q

How does biliary colic present?

A

Sharp RUQ pain, with or without jaundice

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46
Q

Where does the pain in biliary colic radiate to?

A

The back or right shoulder

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47
Q

How long does the pain last in biliary colic?

A

Often lasts longer than 30 minutes, up to a few housr

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48
Q

What other symptoms may be associated with biliary colic?

A

Nausea and vomiting

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49
Q

What might the pain follow in biliary colic?

A

A fatty meal and the symptom of indigestion

50
Q

How should suspected biliary colic be investigated?

A
  • FBC
  • LFTs
  • Lipase
  • Urinalysis
  • CXR
  • ECG
51
Q

How is biliary colic initially managed?

A
  • Analgesia
  • Lifestyle factors
52
Q

What analgesia should be prescribed in biliary colic?

A

Typically NSAIDs and PRN opiods, along with an appropriate antiemetic

53
Q

What analgesic does NICE recommend for severe pain in biliary colic?

A

Diclofenac 75mg IV, unless contraindicated

54
Q

What can be used in severe pain caused by biliary colic when diclofenac is unsuitable or ineffective?

A

IM opioids, e.g. morphine

55
Q

What analgesia should be offered for intermittent mild to moderate pain in biliary colic?

A

Paracetamol or oral NSAID

56
Q

What should be done if there is no improvement with analgesia in biliary colic?

A

Consider possibility of cholecystitis

57
Q

How are lifestyle factors involved in the management of biliary colic?

A

Patients should be advised about lifestyle factors that may help control symptoms and help with future surgery

58
Q

What lifestyle changes should be made in the management of biliary colic?

A
  • Low fat diet
  • Weight loss
  • Increasing exercise
59
Q

What should be provided at discharge for biliary colic?

A

PRN analgesia

60
Q

What is likely following the first presentation of biliary colic?

A

There is a high chance of symptom recurrence or development of complications

61
Q

What are the complications of biliary colic?

A
  • Cholecystitis
  • Acute pancreatitis
62
Q

What is done as a result of the high chance of recurrence/complications in biliary colic?

A

An elective cholecystectomy should be offered

63
Q

How long after presentation should an elective cholecystectomy be offered?

A

Ideally within the first 6 weeks of presentation

64
Q

What surgical technique is used for cholecystectomy?

A

A laproscopic route is preferred, but not always possible

65
Q

What is acute cholecystitis?

A

Inflammation of the gallbladder that develops over hours

66
Q

What does acute cholecystitis usually result from?

A

A stone or sludge impaction in the neck of the gallbladder

67
Q

What are the symptoms of acute cholecystitis?

A
  • Pain
  • Vomiting
  • Fever
  • Local peritonism
  • Gallbladder mass
68
Q

Describe the pain in acute cholecystitis

A

It is continuous epigastric or RUQ pain, which may refer to the right shoulde r

69
Q

What can happen in acute cholecystitis if the stone moves to the CBD?

A

Obstructive jaundice and cholangitis may occur

70
Q

What investigations are done in acute cholecystitis?

A
  • Examination
  • FBC
  • Ultrasound
  • Plain AXR
71
Q

What are the examination signs in acute cholecystitis?

A
  • Murphy’s sign
  • May be able to palpate a phlegmon
72
Q

How is Murphy’s sign detected?

A

By lying two fingers over the RUQ, and asking the patient to breath in

73
Q

What is a positive Murphy’s test?

A

Pain and arrest of inspiration as the inflamed gallbladder impinges on fingers

Must also perform test in the LUQ, as positive result requires no pain on this side

74
Q

What is a phlegmon?

A

A RUQ mass of inflamed adherent omentum and bowel

75
Q

What may the ultrasound show in acute cholecystitis?

A
  • Thick-walled, shrunken gallbladder
  • Pericholecystic fluid
  • Stones
  • Dilated common bile duct (>6mm)
76
Q

What % of gallstones can be seen on plain AXR?

A

About 10%

77
Q

What might a plain AXR show in acute cholecystitis?

A

A ‘porcelain’ gallbladder

78
Q

What is a ‘porcelain’ galbladder associated with?

A

Risk of cancer

79
Q

How should patients with acute cholecystitis be managed initially?

A
  • Started on appropriate IV antibiotics
  • Fluid resuscitation
  • NG tube
  • Concurrent analgesia
80
Q

What antibiotics can be given in acute cholecystitis?

A

Co-amoxiclav, with or without metronidazole

81
Q

What should be done if a patient with acute cholecystitis demonstrates evidence of sepsis?

A

Management should be adapted accordingly

82
Q

When should a NG tube be placed in acute cholecystitis?

A

If the patient is vomiting and made NBM

83
Q

What analgesia should be prescribed in acute cholecystitis?

A

Typically simple analgesics and PRN opioids, and anti-emetics

84
Q

What is the definitive management for acute cholecystitis?

A

Laparoscopic cholecystectomy

85
Q

When should a laparoscopic cholecystectomy be performed in acute cholecystitis?

A

Within 1 week, however ideally within 72 hours of presentation

86
Q

Why are earlier cholecystectomies preferred in acute cholecystitis?

A

Because they are safe, and reduce overall hospital stay

87
Q

When is a percutaneous cholecystectomy performed?

A

In patients not fit for surgery and not responding to antibiotics

88
Q

What is the purpose of a percutaneous cholecystectomy?

A

To drain the infection

89
Q

What should the patient be advised of after a percutaneous cholecystectomy?

A

Lifestyle changes

90
Q

What will patients with chronic cholecystitis typically have a history of?

A

Recurrent or untreated cholecystitis

91
Q

What does recurrent or untreated cholecystitis lead to?

A

Chronic inflammation of the gallbladder wall

92
Q

What are the symptoms of chronic cholecystitis?

A

May be asymptomatic, or symptoms may include;

  • Vague abdominal discomfort
  • Distention
  • Nausea
  • Flatulence
  • Fat intolerance
93
Q

What are the differential diagnoses for chronic cholecystitis?

A
  • Hiatus hernia
  • IBS
  • Peptic ulcer
  • Chronic pancreatitis
  • Tumour
94
Q

How is chronic cholecystitis investigated?

A
  • Ultrasound
  • MRCP
95
Q

What is the purpose of ultrasound in the investigation of chronic cholecystitis?

A

To image stones and assess CBD diameter

96
Q

What is the purpose of MRCP in chronic cholecystitis?

A

To image CBD stones

97
Q

How is chronic cholecystitis managed?

A

Cholecystectomy

98
Q

How is chronic cholecystitis managed if US shows dilated CBD with stones?

A

ERCP and sphincterectomy before surgery

99
Q

What are the complications of chronic cholecystitis?

A

It conveys an increased risk of gallbladder carcinoma and biliary-enteric fistula

100
Q

What is gallbladder empyema?

A

When the gallbladder is infected and an abscess forms within it

101
Q

How do patients with gallbladder empyma typically present?

A

Patients are typically septic, and present with a similar-type picture to acute cholecystitis

102
Q

What is gallbladder empyema associated with?

A

Significant morbidity and mortality

103
Q

How is gallbladder empyema diagnosed?

A

US scan or CT scan

104
Q

How is gallbladder empyema treated?

A

Laparoscopic cholecystectomy

105
Q

What may be required intra-operatively in gallbladder empyema if there is a tense gallbladder?

A

Intra-operative drainage

106
Q

How does the rate of conversion to open cholecystectomy in gallbladder empyema compare to uncomplicated acute cholecystitis?

A

It is higher

107
Q

How can gallbladder empyema be managed if the patient is suitable for surgery?

A

Percutaneous cholecystomy

108
Q

What can inflammation of the gallbladder, typically if recurrent or silent, cause?

A

A fistula to form between the gallbladder wall and the duodenum

109
Q

What does a fistula between the gallbladder and duodenum allow?

A

Gallstones to pass into the small bowel

110
Q

What can gallstones passing into the small bowel via a fistula cause?

A

Bowel obstruction

111
Q

Give two conditions whereby a fistula leads to a gallstone causing bowel obstruction

A
  • Bouveret’s syndrome
  • Gallstone ileus
112
Q

What happens in Bouveret’s syndrome?

A

When a stone impacts to cause duodenal obstruction

113
Q

What happens in a gallstone ileus?

A

The stone impacts to cause obstruction at the terminal ileum (the narrowest part of the adult bowel)

114
Q

What is ascending cholangitis also known as?

A

Acute cholangitis, or just cholangitis

115
Q

What is ascending cholangitis?

A

An infection of the bile duct

116
Q

What causes ascending cholangitis?

A

Typically caused by bacteria ascending from the junction with the duodenum

117
Q

When does ascending cholangitis tend to occur?

A

When the bile duct is already partially obstructed by gallstones

118
Q

Is ascending cholangitis regarded as a medical emergency?

A

Yes, it can be life threatening

119
Q

What are the symptoms of ascending cholangitis?

A
  • Jaundice
  • Fever
  • Abdominal pain
  • In severe cases, low blood pressure and confusion
120
Q

How is ascending cholangitis managed?

A
  • IV fluids and antibiotics
  • Treatment of underlying condition

z - Gastrointestinal (6 decks)

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