Gallstones

Question 1

Risk factors for Gallstones

Answer 1

Female

Fair

Forty

Fertile (pregnant, COCP)

Fat

Question 2

Gallstone composition

Answer 2

Bile pigment stones 5%

Cholesterol stones 20%

Mixed stones 75%

Question 3

Cholesterol gallstones

Answer 3

Large

Often solitary

Question 4

Pigment gallstone

Answer 4

Small

Fragile

Calcium bilirubinate

Associated with haemolysis

Question 5

Mixed gallstones

Answer 5

Often multiple

Question 6

Complications of gallstones

Answer 6

Biliary colic

Acute cholecystitis

Chronic cholecystitis

Mirizzi’s syndrome

Obstructive jaundice

Pancreatitis

Cholangitis

Gallstone ileus

Question 7

Biliary colic pathogenesis

Answer 7

Gallstone impacted in neck of gallbladder (Hartmann’s pouch)

Gallbladder spasm

Question 8

Biliary colic presentation

Answer 8

RUQ pain - radiates to back / scapula

Attacks < 6 hrs

Worse with fatty food

Sweating

Question 9

Investigations for biliary colic

Answer 9

Urine - bilirubin

Bloods

US - acoustic shadow

Question 10

Management of biliary colic

Answer 10

Conservative: NBM + analgaesia + fluids

Surgical : laproscopic cholecystectomy

Question 11

Acute cholecystitis pathogenesis

Answer 11

Gallstone impaction in Hartmann’s pouch+ inflammation+/- Empyema

Question 12

Acute cholecystitis presentation

Answer 12

Contiuous RUQ pain (Radiates to right scapula + epigastrum)

Fever

Vomiting

Question 13

Acute cholecystitis examination findings

Answer 13

Local peritonsim

RUQ

Tachycardia

Shallow breathing

Murphy’s sign

Question 14

Acute cholecystitis investigations

Answer 14

Urine - bilirubin↑WCC

US

MRCP (MRI cholangiopancreatography)

Question 15

Conservative management of acute cholecystitis

Answer 15

NBM + fluids

Question 16

Medical management of acute cholecystitis

Answer 16

Analgesia

Abx: Cefuroxime + Metronidazole

Question 17

Surgical management of acute cholecystitis

Answer 17

Laproscopic cholecystectomy

Question 18

Acute cholecystitis empyema presentation

Answer 18

Fever

RUQ mass

Question 19

Chronic cholecystitis presentation

Answer 19

Vague upper abdo discomfort

Distention

Nausea

Flatulence

Worse with fatty food

Question 20

Chronic cholecystitis investigations

Answer 20

AXR

US - gallstones, fibrotic, shrunken gallbladder

MRCP

Question 21

Management of chronic cholecystitis

Answer 21

Medical: bile salts

Surgical: cholecystectomy

Question 22

Rarer gallstone disease

Answer 22

Mirizzi’s syndrome

Gallstone ileus

Question 23

Mirizzi’s syndrome

Answer 23

Rare

Large stone in gallbladder compresses common hepatic duct

Leads to obstructive jaundice

Question 24

Gallstone ileus

Answer 24

Rare

Large stone errodes from gallbladder to duodenum

May impact in distal ileum and cause obstruction

Rigler’s triad

Question 25

Rigler's triad

Answer 25

Associated with gallstone ileus Pneumobillia Small bowel obstruction Gallstone in RLQ

Question 26

Management of gallstone ileus

Answer 26

Stone removal via enterotomy

Question 27

Bilirubin level where jaundice is noticable

Answer 27

50 - 75 mM Seen at tongue frenulum first

Question 28

Causes of obstructive jaundice

Answer 28

Stones Cancer of pancreas head Mirizzi's syndrome Drugs - COCP, sulfonylureas

Question 29

Obstructive jaundice presentation

Answer 29

Jaundice Dark urine Pale stools (steatorrhoea) Itch

Question 30

Obstructive jaundice investigations

Answer 30

Urine - dark, bilirubin↑WCC Hepatorenal syndrome↑conjugated bilirubin↑ALP and ↑AST/ALT↑INR (decreased vit K) Immune: AMA, ANCA, ANA AXR US MRCP

Question 31

Management of gallstone obstructive jaundice

Answer 31

Conservative:- Monitor LFTs and wait for stone passage ERCP with sphincterotomy and stone extraction Cholecystectomy

Question 32

Ascending cholangitis gallstone location

Answer 32

Common bile duct

Question 33

Ascending cholangitis presentation

Answer 33

Charcot's triad Reynolds pentad

Question 34

Charcot's triad

Answer 34

Fever RUQ pain Jaundice

Question 35

Reynolds pentad

Answer 35

Charcot's triad (Fever, RUQ pain, Jaundice) + shock + confusion

Question 36

Management of ascending cholangitis

Answer 36

Cefuroxime + Metronidazole ERCP with sphincterotomy and stone removal