gallstones (see DM) Flashcards
what is bile composed of (5)
- water (97%)
- bile acids/salts
- bile bigments - biliverdin, bilirubin
- lipids - cholesterol, fatty acids, phospholipids
- electrolytes
what are the functions of bile (6, top two are the major ones)
- emulsification of fats - allow for greater SA for enzyme activity
- neutralises gastric secretions
- absoption of fats and fat-soluble vitamins (ADEK)
- excretion of substances e.g. bile pigments, excess cholesterol
- laxative and lubrication for chyme
- bacteriocidal
what are the 3 main types of gall stones
- cholesterol stones - due to excess cholesterol production
- pigment stones - purely comprised of bile pigments, may arise due to haemolytic anaemaia
- mixed - mixture of the two
why might gallstones not be seen on x-rays
most don’t contain enough calcium to appear opaque on xray
what are the 5 Fs of gallstones (epidemiology)
- fat
- female
- fertile
- forty
- family history
what is a complication of gallstones due to vitamin malabsoption
clotting disorder -> vit K needed in clotting factor synthesis
what conditions may predispose a pt to gallstones (4)
- cystic fibrosis
- cirrhosis
- impaired gall bladder emptying
- haemolytic anaemia
where does the common bile duct drain into
the duodenum
what are some common areas that gallstones can cause blockages at (3)
- cystic duct
- common bile duct
- convergence of common bile and pancreatic duct
where can gallstones cause complications
- in the gall baldder (choleithiasis)
- in the biliary system (choledocholithiasis)
- outside the biliary system (e.g. GI tracts)
complications of gallstones (8)
- biliary colic
- cholecystitis
- mirizzi syndrome (common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder)
- obstructive jaundice
- ascending cholangitis
- acute obstructive suppurative ascending cholangitis
- pancreatitis
- gallstone ileus
what is bilary colic
spasm of cystic duct due to calculi causing blockages
what precipitates bilary colic
large fatty meal
biliary colic presentation
RUQ pain
biliary colic investigations + findings (2)
- bloods - normal
- US - gallstones, thin walled gall bladder
biliary colic mgx (2)
- analgesia
- elective cholecystectomy
what is cholecystitis
inflammation of the gall bladder -> progression of biliary colic leading to inflammation
cholecystitis presentation (3)
- RUQ pain
- murphy’s sign (unable to complete full inspiration when palpating due to pain)
- fever
cholecystitis investigations + findings (2)
- bloods - raised WCC, CRP, normal LFTs
- USS - gallstones, thick-walled gallbladder
cholecystitis mgx (5)
- Abx - broad spectrum (amoxicillin, gentamicin and metraniazole)
- analgesia
- “hot” cholecystectomy (Laparoscopic Cholecystectomy during an acute attack)
- delayed cholecystectomy (after abx etc.)
- cholecystostomy (drainage of gall bladder)
what is mirizzi syndrome
common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
what can mirizzi syndrome progress to form
a fistula
mirizzi syndrome investigations + results (3)
- bloods- raised WBC, CRP, obstructive LFTs (raised ALP and GGT)
- US - gallastones, thick walled gallbladder, dilated intrahepatic ducts
- MRCP
mirizzi syndrome mgx (3)
- abx
- analgesia
- complex surgical mgx
obstructive jaundice presentation (2)
- jaundice
- RUQ pain (if due to gall stones)
what is Courvoisier’s law
if a pt has jaundice and a painLESS enlarged gall bladder it is most likley NOT due to gallstones but some other underlying cause e.g. pancreatic malignancy
obstructive jaundice investigations and results
- bloods - obstructive LFTs (raised ALP and GGT)
- US - dilated common bile duct +/- intrahepatic ducts
- MRCP
obstructive jaundice mgx
dependent on cause
1. Endoscopic retrograde cholangiopancreatography (ERCP);
2. cholecystectomy with CBD exploration
what is ascending cholangitis
biiliary stasis in obstructive jaundice leading to infection
ascending cholangitis presentation (4)
- jaundice
- RUQ pain
- fever
- charcot’s triad (pain, fever, jaundice/rigors)
ascending cholangitis investigations and results (3)
- bloods - obstructive LFTs, raised WBC, raised CRP
- US - dilated common bile duct +/- intrahepatic ducts, thickening of bile duct walls
- MRCP
what is suppurative cholangitis
accumulation of pus in the bile ducts - may lead to increased intrabiliary pressure and sepsis
ascending cholangitis mgx
- abx
- resusitation
- biliary tree decompression - ERCP
suppurative cholangitis presentation (5)
- jaundice
- RUQ pain
- fever
- hypotension
- mental obtundation
(aka reynold’s pentad -> pain, obstructive jaundice, fever, hypotension, mental change)
suppurative cholangitis investigations
- bloods - obstructive LFTs, raised WCC, raised CRP
- US - dilated common bile duct +/- intrahepatic duct
- MRCP
suppurative cholangitis mgx
- abx
- resuscitation
- organ support
- intensive care
- ERCP
pancreatitis presentation
epigastric pain that radiates to the back and is better on leaning forward
pancreatitis investigations and findings
- bloods - amylase >100 or x3 higher than upper limit of normal, or lipase
- US - gallstones
- CT abdo + pelvis
pancreatitis mgx
- supportive care (possibly intensive care)
- cholecystectomy (in uncomplicated cases), can be done immediately or 2 weeks post discharge
what is gallstone ileus
small bowel obstruction caused by an impaction of a gallstone within the lumen of the small intestine due to the formation of a cholecysto-enteric fistula
gallstone ileus presentation (3)
- vomiting
- constipation
- hx of RUQ pain
gallstone ileus investigations and findings (3)
- bloods - may be normal
- XR/CT - aerobilia, bowel obstruction, gallstones at ileocaecal junction (aka Rigler triad)
- CT abdomen/pelvis - rigler triad
what is the rigler triad in gallstone ileus
- small bowel obstruction
- aerobilia - gas within the biliary tree
- gallstones (usually in the right iliac fossa)
gallstone ileus mgx
- resusitation
- NG tube - drain fluid from stomach
- enterolithotomy - the extraction of a stone through an enterotomy, without performing a procedure to resolve the fistula or the gallbladder disease
what is seen in the US of someone w a gallstone (2)
- high attenuation og the gall stone itself
- acoustic shadow below gallstone
what is a porcelain gall bladder
calcification of the gallbladder wall
