Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Core Conditions - Abdominal > Gallstones & Biliary Colic > Flashcards

Gallstones & Biliary Colic Flashcards

1
Q

What is cholelithiasis?

A

cholelithiasis refers to the formation of hard stones in the gallbladder (gallstones)

this typically takes years to occur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How common is cholelithiasis?

Are all of these cases symptomatic?

A

it is very common and affects 10-15% of the general population in the developed world

the vast majority of these cases are asymptomatic and only a small proportion present with complications of gallstones

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Are gallstones themselves problematic?

A

No, gallstones themselves are not problematic in the vast majority of cases

But they can predispose to other problems with the biliary tree

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What % of gallstones lead to further problems with the biliary tree?

What are the most common presentations?

A

Each year, 1 - 4% of gallstones will have an acute presentation of biliary disease

about 60% of these are biliary colic

and 40% are acute cholecystitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How are gallstones generally classified?

A

they are classified as either cholesterol stones or pigment stones

in reality, they are usually mixed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

In what parts of the world are pigment stones and cholesterol stones more common?

A
  • cholesterol stones are more common in the developed world
    • in Europe & the USA, 75% of gallstones are cholesterol stones
  • pigment stones are more common in the developing world
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What do cholesterol stones typically look like?

A

they are usually solitary and large

stones of about 70% or more of cholesterol are usually smaller and more numerous

the rest of the stone is made up of calcium compounds and protein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the 3 risk factors for cholesterol stones?

A
  • female gender
  • advancing age
  • obesity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What do mixed stones tend to look like?

A

there are usually multiple stones and they are irregularly shaped

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How can pigment stones be divided into 2 categories?

What is the difference in appearance / composition?

A

Brown stones:

  • these tend to be softer
  • they contain a mixture of pigment, cholesterol and calcium salts

Black stones:

  • these are much harder and made of pure pigment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Why do women tend to have a higher incidence of gallstones than men?

A
  • cholesterol secretion is a massive factor in gallstone formation - particularly the proportion of cholesterol secreted in relation to the concentration of bile salts
  • women naturally secrete a higher proportion of cholesterol than men
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How does incidence of gallstones change with age?

A

incidence increases with age

  • at age 30 - 5% women and 2% of men have / have had gallstones
  • at age 55 - 20% women and 10% of men have / have had gallstones
  • at age 70 - 30% women and 20% of men have / have had gallstones
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the racial differences in who develops gallstones?

A
  • more common in Scandinavia
  • more common in Native North and South American populations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the 6 main risk factors for developing gallstones?

A
  • weight
    • obesity
    • sudden weight loss
  • family history
  • oestrogen
    • ​female gender
    • oral contraceptive pill
  • diet (high fat, low fibre)
  • increasing age
    • ​stones take time to form
  • diabetes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the 4 Fs that are used to describe the typical patient with gallstones?

A
  • fair
  • fat
  • female
  • forty
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What 3 factors are needed for the formation of cholesterol stones?

A
  • high concentration of cholesterol in the gallbladder
  • gallbladder stasis
  • products that promote the crystallisation of cholesterol
    • some lipoproteins found in bile will do this
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

When do cholesterol stones form?

What is there insufficient quantities of and what process can increase the formation of stones?

A
  • cholesterol stones form when the concentration of micelles is not great enough to hold all the cholesterol within micelles
  • formation of stones is increased during fasting
    • particularly extended fasting (e.g. in IV nutrition)
  • fasting increases the concentration of cholesterol in the gallbladder relative to other solutes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What type of bile pool do patients with cholesterol stones often have?

A

they generally have a smaller bile pool that circulates more often

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the first stage in the formation of cholesterol stones?

A

cholesterol crystals initially form in bile that is supersaturated with cholesterol

this results in the production of “sludge”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What factors inhibit the formation of sludge?

A
  • caffeine
  • NSAIDs
  • bile salts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What factors exacerbate the formation of sludge?

A
  • mucin
  • rapid weight loss
  • pregnancy
  • increased serum cholesterol
    • large amounts of body fat
    • female gender
    • advancing age
    • diabetes / high dietary fat
  • reduced bile production or circulation
    • ​e.g. in malabsorption (like Crohn’s) where so much bile is lost, it cannot be replaced quickly enough
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What 2 drugs can exacerbate the formation of sludge?

A
  • oral contraceptive pill
  • clofibrate
    • a fibrate drug that lowers plasma cholesterol by increasing cholesterol secretion in the bile
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What 2 things can happen to sludge after it has formed?

A
  • it can be reabsorbed
  • it can go on to form cholesterol stones
  • only in 15% of cases will it go on to form stones
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How long does the process of cholesterol stone formation take?

When is a cholecystectomy usually performed?

A
  • it takes around 8 years for a stone to form from the beginning of the initial process
  • in symptomatic patients, a cholescystectomy is usually performed 12 years after the process of stone formation began
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

How is the process of pigment stone formation related to cholesterol stone formation?

Where do pigments in bile come from?

A
  • the process of pigment stone formation is completely independent of that of cholesterol stones
  • pigments in bile are from bilirubin breakdown
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What are the 3 main causes that can lead to pigment stones?

A
  • an increase in bilirubin load, as a result of haemolytic anaemia
  • pigments become less water soluble once in the bile as a result of the action of glucuronidases
  • cirrhosis - due to depletion of glucuronidase inhibitors at the site
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is thought to be the major cause of pigment stones, relating to the action of glucuronidases?

Where is this more common and what is associated with?

A
  • most cases of pigment stones result from the subclinical bacterial colonisation of the gallbladder
  • common in East Asia and associated with E. coli
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What do the stones related to the action of glucuronidases look like?

What about the 2 other causes of pigment stones?

A
  • stones associated with bacterial colonisation tend to be softer and brown and combined with calcium carbonate
  • the other 2 types are smaller, blacker and harder and more commonly encountered in the West
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Which gender is more commonly affected by pigment stones?

A

pigment stones affect both sexes equally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What % of cases of gallstones are symptomatic?

A

90% of cases are asymptomatic and discovered incidentally

32
Q

When do gallstones cause vague upper abominal symptoms?

A

gallstones usually DO NOT cause flatulence, dyspepsia, fat intolerance or other vague upper abdominal symptoms

unless they are causing an acute flare-up of biliary colic or other acute manifestations

33
Q

How can symptomatic gallstones present?

A

symptomatic gallstones can present as:

  • biliary colic
  • cholescystitis (infection in the biliary tree - emergency)
  • pancreatitis
  • other acute manifestations
34
Q

What is biliary colic?

A

it describes an intermittent RUQ / epigastric pain that is associated with a blockage in the bile duct

it is often caused by a stone migrating down the duct

35
Q

What does the term “colic” mean?

What structure is it associated with?

A
  • “colic” means a wave of pain
  • it is associated with a tubular structure surrounded by smooth muscle
  • the wave nature is related to the fact that smooth muscle has its own “pace maker” that causes contractions at certain intervals
36
Q

Why is the name “colic” misleading when describing the pain in biliary colic?

A
  • a true colic increases and decreases in intensity gradually in a rhythmic fashion
  • in biliarly colic, the pain is constant and crescendoes
37
Q

What is the pain in biliary colic associated with?

What can be done to make it better?

A
  • pain is sporadic and associated with eating - particularly fatty foods
  • pain subsides with analgesia
  • pain is usually reduced with modification of diet
38
Q

When does the pain typically come on in biliary colic and how long does it last for?

Can it radiate?

A
  • pain comes on after eating a large and/or fatty meal
  • pain typically appears in the mid-evening and lasts until the early hours of the morning
  • pain may radiate to the right shoulder tip
39
Q

What other symptoms may present at the same time as biliary colic pain?

What does more severe pain suggest?

A
  • nausea and vomiting can occur in severe attacks
  • more severe prolonged pain suggests association with an underlying condition
    • cholescystitis
    • cholangitis
    • gallstone-induced pancreatitis
40
Q

Does biliary colic recur?

Can it go on to develop into something else?

What do LFTs show?

A
  • biliary colic is a recurring condition
    • over a 5-year period, 100% of patients will experience it again
  • 20% of patients go on to develop something more serious - cholecystitis, obstructive jaundice or pancreatitis
  • LFTs usually normal
41
Q
A
42
Q

How does location of gallstones influence the production of abnormal lab test results / symptoms?

A
  • stones within the gallbladder or cystic duct that are causing biliary colic are unlikely to produce abnormal lab test results
  • stones within the common bile duct are more likely to account for symptoms and abnormal lab test results
43
Q

What might be raised on LFTs in cholecystitis?

A
  • raised bilirubin
  • raised ALP
  • raised ALT
  • these may all be slightly raised in the presence of cholecystitis, even without current duct obstruction
44
Q

What does it suggest if ALP and bilirubin are raised higher than ALT?

What if ALT is raised higher than ALP and bilirubin?

A
  • if ALP and bilirubin are raised higher than ALT, this shows an obstructive pattern of LFTs

this tends to signify biliary duct problems

  • if ALT is raised higher than ALP and bilirubin, this usually indicates intra-hepatic pathology
45
Q

How might gallstones be seen on plain AXR?

What else might be seen?

Is this used diagnostically?

A
  • gallstones can only be seen on AXR if they are calcified (10-15% cases)
  • may show gas in the gallbladder as a result of gas-producing organisms
  • may show fistulation of the large bowel
  • AXR is not used diagnostically, but gallstones may be seen incidentally
46
Q

What is the gold standard diagnostic test for gallstones?

A

ultrasound

this is 95% effective at detecting gallstones, but it is operator dependent

47
Q

What can gallstones be confused for on ultrasound?

How can you tell them apart?

A

gallstones can sometimes be confused for polyps on USS and vice versa

you can tell the difference as gallstones will cast a “shadow” underneath them on USS, but polyps will not

48
Q

How can cholecystitis be detected on USS?

What does a “halo effect” around the gallbladder indicate?

A
  • cholecystitis is detectable as a thickening of the gallbladder wall to more than 4mm
  • a “halo effect” around the gallbladder shows oedema surrounding the gallbladder

this can indicate acute viral hepatitis, hypoalbuminaemia or portal hypertension

49
Q

What abnormality in the bile ducts may be seen on USS?

A

ductal dilatation caused by blockage of the bile duct may also be visible

50
Q

What is oral cholecystography?

What do the results mean?

A
  • the patient takes a dose of an oral dye that is absorbed and concentrated by the liver and then secreted in the bile
  • this enables the gallbladder to be seen on radiograph
  • if you cannot see the gallbladder, there could be a blockage in the cystic duct or recent cholecystitis
51
Q

What is the drawback of oral cholecystography?

What is the false negative rate of this test?

A
  • even when the test works correctly, some stones are too small to see
  • false negatives occur 5% of the time
  • used in conjunction with USS, the false negative rate is reduced to 2%
52
Q

When might ERCP be used for investigating gallstones?

A
  • used when the history is very suggestive of gallstones, but no stones are seen on USS or cholecystography
  • a sample of bile is often taken and examined histologically for cholesterol crystals and debris
53
Q

Why might serum and urinary amylase be measured in gallstone disease?

A
  • a stone passing through the very last part of the common bile duct can get lodged and cause pancreatitis
  • serum amylase returns to normal levels if conditions return to normal
  • urinary amylase can remain elevated for up to 5 days
54
Q

What is Courvoisier’s sign?

How do gallstones typically affect the size / appearance of the gallbladder?

A

Courvoisier’s sign involves a palpable gallbladder

the law states that a palpable gallbladder in the presence of painless jaundice is unlikely to be gallstones

gallstones typically result in a fibrotic shrunken gallbladder, which will not usually distend, and thus will not usually be palpable

55
Q

What is gallbladder distension usually a sign of?

A

gallbladder distension is usually a sign of acute pathology

e.g. pancreatic malignancy / obstruction of the pancreas

56
Q

What are the differential diagnoses of gallstones?

A
  • GORD
  • peptic ulcers
  • irritable bowel syndrome
  • pancreatitis
  • tumour
    • stomach
    • pancreas
    • large bowel
57
Q

What are the 5 main complications of gallstones?

A
  • acute and chronic cholecystitis
  • acute cholangitis
  • pancreatitis
  • fistulation
  • increased risk of adenocarcinoma of the wall of the gallbladder
58
Q
A
59
Q

How can fistulation result from gallstones?

What is gallstone ileus?

A

gallstones may perforate the gallbladder and form a fistula, often to the colon or small intestine

a gallstone passing into the small intestine may cause a blockage in the ileum - this is gallstone ileus

60
Q

What is choledocholithiasis?

What is it commonly accompanied by?

A
  • stones pass out of the cystic duct and into the bile duct
  • this causes obstructive jaundice
  • this is commonly accompanied by cholangitis (bacterial infection of the gallbladder)
61
Q

What is the treatment for asymptomatic gallstones?

A

asymptomatic gallstones are usually not treated

62
Q

What treatments are given for the management of biliary colic?

A
  • IV morphine
    • 5 - 10mg / 4 hours
  • anti-emetic
    • ​e.g. domperidone, metoclopramide, cyclizine
63
Q

What procedure is sometimes offered to patients with severe biliary colic?

How is this procedure performed?

A

elective cholecystectomy

  • this is accompanied by cholangiography (imaging of the bile ducts using X-ray)
  • performed under general anaesthetic after 4 hours of fasting
64
Q

What prophylactic treatments are given following elective cholecystectomy?

A
  • DVT prophylaxis is given if the patient is over 40
  • prophylactic antibiotics are also usually given if the patient is over 40

this is a single dose of a second generation cephalosporin (e.g. cefuroxime)

this may be continued for 24-48 hours after the operation in the presence of sepsis

65
Q

What is involved in an open cholecystectomy?

Why must a catheter be placed in the bile duct?

A
  • there is a 10% chance that the patient will have a gallstone in the bile duct at the time of operation
  • a catheter is inserted into the bile duct and dye squirted into it to outline the biliary tree
  • if there is a stone present, it is removed
  • after this, the gallbladder is removed
66
Q

Why do some surgeons leave a drain in place of the gallbladder for a few days following open cholecystectomy?

Why is this not usually done?

A
  • some people have small ducts that take bile directly to the gallbladder, and these may leak
  • the drain is a cause of post-operative pain
  • the evidence to suggest it improves the outcome from bile leak is limited
67
Q

What is involved in laparoscopic cholecystectomy?

A
  • camera inserted in the umbilicus and 3 other incisions are made for the instruments
  • once the gallbladder is removed, it is important to check for leaks
  • gallbladder is usually removed via the umbilicus
  • peritoneal cavity is then washed out and cleaned up
68
Q

What is involved in the post-operative care following open cholecystectomy?

A
  • pain relief and nil-by-mouth for up to 48 hours following procedure
  • IV fluids are required for 2 days as a result of the nil-by-mouth
  • low dose heparin to reduce risk of thrombosis
  • older patients may need physiotherapy and/or early mobilisation to avoid atelectasis (collapse of the lung)
69
Q

What is the difference in the recovery following laparoscopic cholecystectomy?

A
  • patients have considerably less pain and ileus than open surgery
  • most are mobile sooner and there is less need for physio
70
Q

What can happen to the Sphincter of Oddi as a complication of cholecystectomy?

A

sphincter of Oddi dysfunction can be a cause of post-operative pain

it is often due to trauma sustained during the operation

71
Q

What is post-cholecystectomy syndrome?

What does it mean about the surgery and what is actually causing pain?

A
  • biliary type pain that occurs months or years after cholecystectomy
  • patients describe the pain as being identical to that for which the operation was carried out
  • it means that the cholecystectomy was not needed as the gallbladder / stones was not the cause of pain
  • pain is caused by functional colonic disease, where there is spasm at the hepatic flexure (hepatic flexure syndrome)
72
Q

Why might a sphincterotomy be required following cholecystectomy?

A
  • there may be hypertension of the sphincter of Oddi (it does not relax)
  • this can be confirmed by imaging of the bile duct showing dilated bile ducts when the pain is present and lack of retained stone
  • it is treated by sphincterotomy
73
Q

What is cholestasis?

A

a condition affecting the liver in which bile cannot flow from the liver to the duodenum

74
Q

What are intrinsic causes of bile duct obstruction?

A
  • gallstones in the common bile duct
  • cholangitis
  • carcinoma of the bile duct
  • carcinoma of the gallbladder
  • benign post-traumatic stricture
  • sclerosing cholangitis
  • haemobilia
75
Q

What are extrinsic causes of biliary duct obstruction?

A
  • carcinoma of the pancreas
  • carcinoma of the ampulla of Vater
  • metastatic carcinoma
  • lymphoma
  • acute and chronic pancreatitis
  • pancreatic cysts
  • congenital causes
  • biliary atresia
  • choledochal cyst
  • congenital intrahepatic biliary dilatation (Caroli’s disease)

Core Conditions - Abdominal (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions