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Junior Surgery- GI > Gallstones, Acute cholecystitis and ascending cholangitis > Flashcards

Gallstones, Acute cholecystitis and ascending cholangitis Flashcards

1
Q

What are the components of bile?

A
  • Bile salts - Synthesised in liver, solubilise fat
  • Lecithin - Synthesised in liver, solubilise fat
  • Cholesterol - Synthesised in liver, solubilise fat
  • Bile Pigments - Bilirubin (from haemoglobin)
  • Toxic Metals - Detoxified in liver
  • Bicarbonate - Neutralisation of acid chyme (secreted by duct cells)
  • Water
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2
Q

How is bile pigmented?

A

Breakdown products of haemoglobin from old/damaged erythrocytes -> Bilirubin (predominant bile pigment)

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3
Q

How is bile secreted and reabsorbed?

A

Before secretion, bile acids are conjugated with glycine or taurine. This makes bile more soluble. Bile salts are then secreted by the following pathway:

Liver -> bile duct -> duodenum -> ileum

Secreted bile salts recycled via SMV and enterohepatic circulation

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4
Q

What structure controls the release of bile?

A

Sphincter of Oddi

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5
Q

What substance causes relaxation of the sphincter of oddi?

A

CCK

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6
Q

What substance causes contraction of the gallbladder?

A

CCK

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7
Q

What causes release of CCK?

A

Fat in the duodenum

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8
Q

What are the layers of the gallbladder?

A
  • Mucosa - folded rugae -> expansion
  • Muscularis - smooth muscle
  • Serosa - connective tissue
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9
Q

Where does bile from the liver decant into when it backs up from the spinchter of oddi?

A

Backs up into the biliary system, and decants into the gallbladder

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10
Q

What determines the concentration of bile?

A

Length of time in the gallbladder -> more time in the gallbladder the more concentrated

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11
Q

What are the main types of gallstones?

A
  • Cholesterol stones
  • Pigment stones
  • Mixed
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12
Q

What are general risk factors for the development of gallstones?

A

4 Fs

  • Fourty
  • Female
  • Fat
  • Fertile
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13
Q

What are risk factors for the development of cholesterol gallstones?

A
  • Obesity
  • Ileal disease
  • Cirrhosis
  • Cystic fibrosis
  • DM
  • TPN
  • Heart transplant
  • Delayed GB emptying
  • Long-term low-fat diet
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14
Q

What are risk factors associated with the development of pigment gallstones?

A
  • Haemolytic anaemia
  • Bile infection (e-coli, Bacteroides)
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15
Q

What is Admirand’s triangle?

A

Increased risk of cholesterol stone if:

  1. Decreased lecithin
  2. Decreased bile salts
  3. Increased cholesterol
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16
Q

How can gallstones present?

A

Can be asymptomatic -> only symptomatic if cystic duct obstruction or passed into common bile duct:

  • Biliary colic - lasts for < 6 hours
    • Can radiate to epigastrium, right shoulder and back
  • Bloating
  • Dyspepsia
  • N+V
  • Features of Complications
    • Jaundice
    • Acute cholecystitis
    • Ascending cholangitis
    • Pancreatitis
    • Gallstone ileus
    • Empyema/Mucocele
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17
Q

What are symptoms of acute cholecystitis?

A
  • Biliary colic initially - Continuous epigastric/RUQ pain -> becomes more severe
  • Local peritonism
    • Can become generalised if perforation occurs
  • Nausea and Vomiting
  • Fever
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18
Q

Where can pain from the gallbladder radiate to?

A

Back, right shoulder and right subscapular region

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19
Q

What are signs of acute cholecystitis?

A
  • Signs of local/generalised peritonism - RUQ Tenderness, Guarding, rigidity
  • Palpable tender Gallbladder
  • Pyrexia
  • Murphy’s Sign
  • Phelgmon present
  • May have jaundice
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20
Q

What is murphy’s sign?

A

As the examiner palpates the abdomen below the right subcostal margin, the patient is asked to take a deep breath in and, if on doing so, is caught by sudden pain, this is Murphy’s sign.

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21
Q

What is murphy’s sign a sign of?

A

Cholecystitis

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22
Q

What is the mechanism behind murphy’s sign?

A

On deep inspiration the lungs expand, pushing the liver downwards so the inflamed gallbladder is pushed onto the examiner’s pressing hand, causing an unexpected sharp pain.

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23
Q

What is a phlegmon?

A

RUQ mass of inflammed adherent omentum and bowel

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24
Q

What are feautres of chronic cholecystitis?

A

Chronic inflammation +/- colic - Flatulent dyspepsia:

  • Vague abdominal discomfort
  • Distention
  • Nausea
  • Flatulence
  • Fat intolerance
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25
Q

How can juandice occur with gallstones?

A

Stones travel into the common bile duct and become lodged, causing obstructive jaundice

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26
Q

What is acute/ascending cholangitis?

A

An infection of the bile duct (cholangitis), usually caused by bacteria ascending from its junction with the duodenum (first part of the small intestine). It tends to occur if the bile duct is already partially obstructed by gallstones

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27
Q

What is a gallstone ileus?

A

A stone which erodes through the gallbladder into the duodenum, which can lead to obstruction of the terminal ileum. The stone leaves a biliary enteric fistula

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28
Q

What is gallstone empyema?

A

Obstructed gallbladder fills with mucus (secreted by the GB wall) and pus

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29
Q

What is Mirizzi’s Syndrome?

A

A stone in the Gallbladder presses on the bile duct causing jaundice

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30
Q

What are complications of gallstones that can occur in the gallbladder and cystic duct?

A
  • Biliary Colic
  • Acute/Chronic cholecystitis
  • Mucocele
  • Empyema
  • Carcinoma
  • Mirizzi’s syndrome
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31
Q

What complications of gallstones can occur in the bile duct?

A
  • Obstructive jaundice
  • Acute Cholangitis
  • Pancreatitis
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32
Q

What complications of gallstones can occur in the gut?

A

Gallstone ileus

33
Q

What are features of ascending cholangitis?

A
  • Charcot’s Triad
    • RUQ pain
    • Jaundice - pale stool, dark urine, pruritis, steatorrhoea
    • Fever/Rigors
  • Reynold’s pentad
    • Charcot’s triad plus shock and altered mental status
34
Q

What is choledocholithiasis?

A

Denotes the presence of gallstones within the bile ducts (common hepatic duct, common bile duct)

35
Q

What are features of billiary colic?

A
  • RUQ pain -> radiates to the back and right shoulder
  • Constant, crescendo characteristic
  • Related to overindulgence/high fat foods
  • Nausea and vomiting in severe attacks
36
Q

What are features of choledocholithiasis?

A

Painful obstructive jaundice

  • RUQ pain
  • Post-hepatic jaundice features
    • Dark urine
    • Pale stool
    • Pruritus
    • Steatorrhoea
  • Features of acute pancreatitis
  • Features of ascending cholangitis
37
Q

What is reynold’s pentad?

A

Features of ascending cholangitis:

  • RUQ pain
  • Fever
  • Jaundice
  • Shock
  • Altered mental status
38
Q

What investigations would you do if you suspected someone had gallstones?

A
  • Bloods - FBC, LFT’s, Amylase, Lipase
  • Abdo US +/- MRCP
  • Consider EUS
  • Consider ERCP
  • Consider CT abdo
39
Q

Why might you perform an FBC in someone with suspected gallstones?

A

Look for elevated WCC - indicative of complication such as acute cholecystitis, cholangitis or pancreatitis

40
Q

Why might you perform LFTs in someone with suspect gallstones?

A

For biliary pain with/without jaundice - check specific aspects of function tests which may indicate cause

41
Q

What might LFTs show in someone with cholelithiasis?

A

Normal

42
Q

What is the difference between cholelithiasis and choledocholithiasis?

A

Cholelithiasis is the presence of solid concretions in the gallbladder. Gallstones form in the gallbladder but may exit into the bile ducts (choledocholithiasis)

43
Q

When do symptoms normally occur in cholelithiasis?

A

When a stone obstructs the cystic, bile or pancreatic duct

44
Q

What might you find on LFTs in someone with choledocholithiasis?

A

Obstructive pattern

  • Elevated ALP
  • Elevated conjugated bilirubin
  • May have transiently elevated ALT
45
Q

Why might you look at serum amylase and lipase in someone with suspected gallstones?

A

Look for signs of pancreatitis - Both elevated

46
Q

What would you be looking for on Abdominal US in someone with suspected gallstones?

A

Look for stones in the gallbladder and echogenic shadow - best for visualisation of gallbladder

Can also be used to visualise choledocholithiasis, but less sensitive

47
Q

Why might you do an MRCP in someone with suspected gallstones?

A

For suspected choledocholithiasis that is not confirmed by Abdo US

48
Q

What can MRCP show in someone with suspected gallstones?

A

Stones in the gallbladder or bile duct

49
Q

When woudl you consider performing EUS when investigating choledocholithiasis?

A
  • Suspected choledocholithiasis not confirmed by abdominal US - particularly in patients who cannot undergo an MRCP (claustrophobia, implanted devices)
  • To confirm choledocholithiasis in high-risk patients prior to a therapeutic ERCP
50
Q

When would you consider doing a CT abdo in someone with suspected gallstones?

A

Used to investigate suspected ascending cholangitis or gallstone pancreatitis

51
Q

What are features of ascending cholangitis on CT Abdo?

A

Bile duct dilatation, wall thicking/outpouchings with choledocholithiasis

52
Q

What non-operative interventions would you consider using to treat gallstones?

A
  • Dissolution
  • Lithotripsy
  • Papillary balloon dilatation
53
Q

How would you manage symptomatic cholelithiasis?

A
  • Analgesia
  • NBM
  • Rehydrate
  • Elective Laproscopic cholecystectomy
54
Q

How would you manage asymptomatic cholelithiasis?

A

Observation

55
Q

How would you manage Choledocholithiasis?

A

With symptoms

  • Analgesia
  • NBM
  • Rehydrate

With or without symptoms - Elective procedures:

  • 1st line - ERCP with biliary sphincterectomy +/- lithotripsy/papillary balloon dilation/Long term stenting
  • 2nd line - Laproscopic common bile duct exploration
56
Q

How would you manage someone with acute cholecystitis?

A
  • NBM
  • Analgesia
  • IV fluids
  • Consider IV antibiotics
  • Laparoscopic cholecystectomy
57
Q

What antibiotics would you consider using to treat someone with acute cholecystitis?

A

Duration 7 days

  • IV amoxicillin + Gentamicin +/- Metranidazole (Co-timoxazole if penicillin allergic)
  • Switch to oral Doxycycline +/- Metranidazole
58
Q

If you were managing an elderly individual with acute cholecystitis, how would you manage them if they were unsuitable for laparoscopic cholecystectomy?

A

Percutaenous cholecystostomy with intention for later cholecystectomy

59
Q

How would you manage chornic cholecystitis?

A

Consider ERCP + Sphincterotomy before performing definitive Cholecystectomy

60
Q

How would you manage someone with Obstructive jaundice caused by CBD stones?

A

Consider the following

  • ERCP with sphincterotomy +/- biliary trawl
  • Laparoscopic exploration/Trans-hepatic exploration
  • Cholecystectomy
61
Q

When would you consider ITU admission in someone with acute cholecystitis?

A

Suspected gangre/perforation

62
Q

What antibiotics would you consider giving someone with acute cholangitis?

A

Duration 7 days

  • IV amoxicillin + Gentamicin +/- Metranidazole (Co-timoxazole if penicillin allergic)
  • Switch to oral Doxycycline +/- Metranidazole
63
Q

What investigations would you consider doing in someone with ascending cholangitis?

A
  • Bloods - FBC, U+E’s, ABG, LFTs, CRP, Blood cultures, Coag screen
  • Abdo ultrasound
  • ERCP
  • CT abdo with IV contrast
  • MRCP
  • Consider Trans-hepatic cholangiography
64
Q

What might you find on FBC in someone with acute cholangitis?

A
  • Increased WCC
  • Decreased platelets
65
Q

What might you find on U+Es in someone with ascending cholangitis?

A
  • Raised urea - in severe cases
  • Creatinine raised - severe cases
  • Hypokalaemia
  • Hypomagnasemia
66
Q

Why would you consider doing an ABG in someone with suspected ascending cholangitis?

A

Suspicion of sepsis - may have metabolic acidosis

67
Q

Why might you perform a coagulation screen on someone with features of ascending cholangitis?

A

Suspiciion of sepsis - May have raised PT

68
Q

When would you consider ordering a MRCP in suspected ascending cholangitis??

A

If Abdo US and CT are negative, but still high suspicion for chlangitis

69
Q

How would you mange someone with ascending cholangitis?

A

ABCDE - if septic

  • IV antibiotics
  • Analgesia - morphine, pethidine, fentanyl
  • Biliary decompression
    • 1st line - ERCP + sphincterectomy + drainage stent
    • 2nd line
      • Choledochotomy
      • Cholecystectomy + CBD exploration
70
Q

What might you find on LFT in someone with ascending cholangitis?

A

Obstructive pattern

  • Hyperbilirubinaemia - conjugated
  • Raised AST/ALT
  • Raised ALP
71
Q

What are indications for open cholecystectomy?

A
  • Difficult LC
  • Complications during LC
  • Complications of acute cholecystitis
72
Q

What type of incision is performed for an open cholecystectomy?

A

Right subcostal incision

73
Q

What are indiciations for cholecystomstomy?

A

Cholecystectomy deemed not to be safe

74
Q

What complications can occur from a cholecystectomy?

A

Early

  • Intra-abdominal collection
  • Bile leak
  • Pancreatitis
  • Jaundice
  • Bile duct injury
  • Retained CBD stone

Late

  • Biliary stricture
75
Q

What are indications for surgical exploration of CBD?

A

CBD stones that could not be cleared by ERCP

76
Q

What are indications for Biliary reconstruction?

A
  • CBD injury
  • CBD stricture
  • Part of another operation
77
Q

What procedure is most often used for biliary reconstruction?

A

Roux-en-Y Hepaticojejunostomy

78
Q

What are the 5 F’s of which increase risk of gallstone formation?

A
  • Fat
  • Female
  • Fair
  • Fertile
  • Forty

Junior Surgery- GI (43 decks)

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