Gallstones, Cholecystitis and Ascending Cholangitis Flashcards
What are 3 different types of gallstone?
- cholesterol stones (20%)
- pigment stones (5%)
- mixed stones (75%)
What are the risk factors for cholelithiasis/gallstone disease?
- increasing age
- female sex
- hispanic + native-american ethnicity
- FHx of gallstones
- gene mutations
- pregnancy/exog oestrogen
- obesity, diabetes
- non-alcoholic liver disease
- TPN
What is the composition of bile?
- bilirubin - by-prod of haem degradation
- cholesterol - kept soluble by bile salts + lecithin
- bile salts/acids - mostly reabsorbed in terminal ileum
- lecithin - increases solubility of cholesterol
- inorganic salts - sodium bicarb to keep bile alkaline to neutralise gastric acid in duodenum
- water - makes up 97% of bile
What is the pathogenesis of cholesterol stones forming?
- imbalance between bile salts/lecithin and cholesterol
- allows cholesterol to precipitate out of solution and form stones
What is the pathogenesis of pigment stones forming?
- occur due to excess of circulating bile pigment
- eg. haemolytic anaemia
What other factors influence pathogenesis of gallstones?
- stasis (eg. pregnancy)
- ileal dysfunction (prevents re-absorption of bile salts)
- obesity and hypercholesterolaemia
What are the clinical features of biliary colic?
- intense RUQ/epigastric pain
- radiates to right side
- might radiate to tip of shoulder/back
- nausea and vomiting
- postprandial pain
What are complications of gallstones?
- biliary colic
- acute cholecystitis
- GB empyema, gangrene, perforation
- obstructive jaundice
- ascending cholangitis
- pancreatitis
- gallstone ileus
What are differential diagnoses for RUQ pain?
- gallstone disease (+ related complications)
- gastritis/duodenitis
- peptic ulcer disease/perforated peptic ulcer
- acute pancreatitis
- right lower lobe pneumonia
- MI
How would you differentiate between the gallstone complications?
What link does Crohn’s disease have to gallstones?
- Crohn’s predisposes to development of gallstones
- Due to malabsorption of bile salts from terminal ileum
- Affected individual becomes depleted in bile salts
- They do not have enough bile to maintain the cholesterol dissolved in bile
- Thus cholesterol stones form
What investigations can be done for gallstones?
- Ultrasound of gallbladder -> identify 90% of gallstones
- Liver function tests to assess liver fxn
What ducts meet to form the common bile duct?
- Cystic duct from gallbladder
- Common hepatic duct (from R + R hepatic ducts)
- Come together to form common bile duct (outside the liver)
Remember, most patients with gallstones are asymptomatic. How might patients with symptomatic gallstones present?
- Biliary colic or cholecystitis (>90% of symptomatic presentations)
- Jaundice +/- ascending cholangitis
- Acute pancreatitis
- Gallstone ‘ileus’
How does a biliary colic come about and how does this present?
- if a gallstone impacts in + obstructs the cystic duct
- the gallbladder will contract against the acutely obstructed duct
- resulting in symptoms of biliary colic:
- upper abdo/RUQ pain, may radiate to back/tip of scapula, often nausea + vomiting
If imaging shows gallstones + history compatible then laparoscopic cholecystectomy
How does acute cholecystitis develop from a gallstone?
- if the impacted stone occludes cystic duct for a prolonged period of time
- it will rub + damage the mucosal lining
- thereby inciting an acute inflammatory response in gallbladder wall
- there is development of acute cholecystitis
- presence of fever indicates acute cholecystitis (or cholangitis)
Imaging (USS) + cholecystectomy (ideally <48hrs of presentation)
What is acute acalculous cholecystitis?
- acute cholecystitis without gallstones
- thought to result from ischaemia
- the cystic artery is an end artery w/ no collateral circulation
- it occurs in pts who are hospitalised for conditions unrelated to gallbladder eg. hypotension + multiorgan failure; major trauma/burns; infections
- clinical symptoms tend to be insidious since they are obscured by underlying condition
- a high % of pts have no symptoms referable to gallbladder; diagnosis therefore rests on a high index of suspicion
- as a result of either delay in dx or disease itself, incidence of gangrene + perforation is much higher in acalculous cholecystitis than cholecystitis due to gallstones
Rx → if pt fit then cholecystectomy, if unfit then percutaneous cholecystectomy
What is chronic cholecystitis?
- repeated episodes of biliary colic + acute cholecystitis
- results in chronic inflammation w/ healing by fibrosis
- as a consequence, gallbladder wall becomes thickened + the gallbladder shrinks in size
How do gallstones cause jaundice?
- if a gallstone impacts + obstructs the common bile duct (choledocholithasis), it will cause obstructive jaundice
- the jaundice develops bc bile is unable to drain into the duodenum for excretion
A serious complication of a gallstone obstructing the common bile duct is the development of ascending cholangitis. What is this?
- inflammation of common bile duct
- the biliary obstruction causes stasis
- predisposes to superimposed infection: gut bacteria (usually gram negative eg. E coli, Klebsiella) gain entry to biliary tree via ampulla of Vater
Rx → fluids, broad-spectrum IV Abx, correct coagulopathy, early ERCP
How does ascending chlangitis typically present clinically?
- Charcot’s triad
- jaundice, fever (usually w rigors) + RUQ pain
What happens if ascending cholangitis is left untreated?
- infection may ascend up to the liver
- causing abscesses
- and/or cause sepsis
- serious condition if left untreated has a high mortality
Gallstones are the commonest cause of acute pancreatitis. How do gallstones cause acute pancreatitis?
- if gallstone passes down common bile duct
- obstructs Ampulla of Vater
- results in pancreatitis
- there is reflux of pancreatic secretions back up the pancreatic duct -> pancreatic autodigestion -> pancreatitis
What is gallstone ‘ileus’?
- When a large gallstone causes small bowel obstruction
- Stone erodes through gallbladder into duodenum; then obstructs terminal ileum
- Gallstone enters the small bowel via a fistula, which forms between the inflamed wall of GB and a loop of small bowel
Rx → laparotomy + removal of gallstone from small bowel: enterotomy must be made proximal to site of obstruction + not at site of obstruction. Fistula between gallbaldder + duodenum should not be interfered with
Why is gallstone ‘ileus’ a misnomer?
- Ileus is characterised by cessation of normal peristaltic movements of bowel, typically a rxn of the bowel to any form of irritation around it (eg. post-op, peritonitis)
- If a gallstone obstructs the small bowel, the small bowel proximal to the obstruction will attempt to overcome the blocokage by vigorous peristalsis
Hence, the term gallstone ‘ileus’ is incorrect
What is cholangiocarcinoma?
- second most common type of liver malignancy
- arise in bile ducts
- 80% arise in extra hepatic biliary tree
- most pts present w/ jaundice + majority of these pts are late-stage
- primary sclerosing cholangitis is main risk factor
- in deprived countries → typhoid + liver flukes major risk factors
How is diagnosis of cholangiocarcinoma made?
- LFTs → obstructive picture
- CA 19-9, CEA + CA 125 → elevated
- CT/MRI + MRCP imaging methods of choice
What is the treatment of cholangiocarcinoma and its prognosis?
- best chance of cure = surgical resection
- local invasion of peri hilar tumours is a particular problem + this coupled with lobar atrophy will often contraindicate surgical resection
- palliation of jaundice important, although metallic stents should be avoided in those considered for resection
Prognosis is poor, 5-10% 5 year survival
