GI 2 Flashcards
Who classically gets gallstones?
Fair, fat, fertile, female, forty
What are the main components of bile?
Cholesterol
Bile pigments from broken down Hb
Phospholipids
What are the main 2 different types of gallstones?
How are they different?
Cholesterol stones
- 90% stones in UK
- Large, often solitary
- Caused by obesity
Pigment stones
- Small, irregular
- Friable (easily crumbled)
- Caused by haemolysis, stasis and infection
What is Admirand’s triangle? (what increases your risk of stone)
Increased risk of stone if:
- Low lecithin (essential fat)
- Low bile salts
- High cholesterol
How do gallstones present if they are symptomatic?
Asymptomatic (70%)
Symptoms include
- Colicky RUQ pain
•worse after eating
•refers to right shoulder
•pain as they are being passed through ducts (spasm of smooth muscle)
•lasts about 15 mins , resolves with analgesia
-May have nausea + vomiting
Managment of gallstones?
Gallstones
- NBM
- analgesia (IM Diclofenac)
- IV fluids
- Laperoscopic cholesystectomy (to reduce risk of comps)
Complications of gallstones?
Gallstone complications
- Bilary colic (stuck in cystic duct or passing through CBD)
- Cholecystitis (36%)
- Cholangitis
- Pancreatitis
- Gall stone illeus
- Carcinoma (dunno how)
What is acute cholecystitis?
What are the symptom and signs?
Acute cholecystitis
-gall stone stuck in cystic duct→INFLAMATION
Symptoms - RUQ/epigastric pain (more painful than simple binary colic) •refers to right shoulder •colicky or constant •worse when eating - Nausea Vomiting
Signs
- Fever- the presence of fever distinguishes from just biliary colic
- local peritonism- tender o/e with possible GB mass with guarding and some rigidity
○ MURPHY’S SIGN 2 fingers over RUQ and ask patient to breath in . (only +ve if the same test in the LUQ does not cause pain)
What are the signs of acute cholecystitis?
Acute cholecystitis
- GB mass at RUQ (gall stone)
- Murphy’s sign (palpate RUQ, breathe in, ↑pain)
- NON peritonitic (may have “local peritonism”)
What is the best imaging for looking at gallstones?
USS is best for looking for gallstones
Investigations for acute cholesystis?
Cholecystitis investigations
- FBC (high WCC)
- LFTs (marginal elevation of ALP, bili and ALT possible - but highly elevated levels might be more suggestive of bile tract obstruction)
- USS might show thick walls and shrunken GB, might see stones and might see a dilated CBD
Acute cholecystitis management?
Acute cholecystitis management
- NBM
- analgesia
- IV fluids
- IV antibiotics (guidelines) (cefuroxime)
Refer for laparoscopic cholecystectomywithin 1 week!
**if perforation: do open surgery
What is cholangitis?
What are the classic symptoms?
What is the treatment?
Cholangitis
- Stone in the common bile duct (no bile can get through)
- This is similar to cholecystitis PLUS JAUNDICE
- It’s bad! likely septicaemia!
- Infection of the gall bladder
-CHARCOT’S TRIAD:
•RUQ pain
•Fever and rigors
•Jaundice
Treatment
- IV antibiotics (guidelines)
- ERCP to drain GB
- cholesystectomy if due to stones
Compare the below things for bilary colic/cholysistis/cholangitis.
Location of stone RUQ pain Blood results Murphys sign Jaundice? Fever? Treatment
Location of stone
- bilary colic: in gall bladder
- cholysistis: in cystic duct (neck of gallbladder)
- cholangitis: in common bile duct (obstructing bile flow)
RUQ pain
- bilary colic: yes
- cholysistis: yes
- cholangitis: yes
Blood results
- bilary colic: normal
- cholysistis: ↑WCC
- cholangitis: ↑WCC
Murphys sign
- bilary colic: -ve
- cholysistis: +ve
- cholangitis: Can be +ve
Jaundice?
- bilary colic: no
- cholysistis: no
- cholangitis: yes
Fever?
- bilary colic: no
- cholysistis: yes
- cholangitis: yes
Compare the treatments for bilary colic/cholysistis/cholangitis.
Bilary colic: Laparoscopic cholecystectomy (timing depends on clinical picture)
Acute cholysystitis:
Refer for laparoscopic cholecystectomywithin 1 week!
Cholangitis:
- IV antibiotics (guidelines)
- ERCP to drain GB
- cholesystectomy if due to stones
What is the managment for chronic cholesystis?
Do an USS
-if USS shows dilated CBD with stones do an ERCP + sphincterotomy before laparoscopic cholecystectomy
What are the 2 types on inguinal hernias?
Which ones are more often strangulated?
Inguinal Hernias (75% of abdominal wall hernias)
Indirect (most common 80%)
- internal ring → external inguinal ring
- can strangulate
Direct (less common 20%)
- directly through posterior wall of inguinal canal
- rarely strangulate
*located SUPERO MEDIAL to pubic tubercle
What are the risk factors for inguinal hernias?
Risk factors-Inguinal hernias
- MALES (8:1)
- chronic cough
- obesity
- constipation/urinary obs
- heavy lifting
- prev abdo surg