GI - Acute And Chronic Cholecystitis + Rarer Gallstone Diseases

Question 1

Acute cholecystitis: pathogenesis

Answer 1

• Stone or sludge causes impaction in Hartmann’s pouch (GB distends and compromises vascular supply)
• Can have chemical and/or bacterial inflammation
• 5% are acalculous: sepsis, burns or DM

Question 2

Acute cholecystitis: 4 sequelae

Answer 2

• Resolution
• Gangrene/rarely perf
• chronic cholecystitis
• empyema

Question 3

Acute cholecystitis: presentation

Answer 3

• Severe RUQ pain (pt will lie still - local peritonitis)
• Continuous pain (lasts longer than biliary colic)
• radiates to right scapula and epigastrium
• fever
• vomiting

Question 4

Acute cholecystitis: examination - 3 general features and 3 signs

Answer 4

General features

• local peritonism in RUQ
• Tachycardia with shallow breathing
• +/- jaundice

Signs

• Murphy’s sign: 2 fingers over the GB, ask pt to breathe in (pain and breath catch + must be negative on left side)
• Phlegmon may be palpable: mass of adherent omentum and bowel
• Boas’ sign: hyper aesthetic below right scapula

Question 5

Acute cholecystitis: Ix

Answer 5

• Urine: bilirubin/urobilinogen
• Bloods: FBC (raised WCC), U+E (dehydration from vomiting), amylase, LFTs, G+S, clotting and CRP
• Imaging: AXR (calcification of GB wall/gallstone), erect CXR (perf?), US (look for acoustic shadow, dilated ducts, wall oedema [inflammed GB])
• MRCP or HIDA cholescintigraphy

Question 6

Acute cholecystitis: Mx - conservative

Answer 6

• NBM
• fluid resus
• analgesia: paracetamol, diclofenac, codeine
• ABX: local guideline trust (Kettering = coamoxiclav and metronidazole)
• 80-90% pts settle over 24-48h
• Can deteriorate and perf/empyema

Question 7

Acute cholecystitis: Mx - surgical

Answer 7

• Elective lap chole at 6-12wks

- If <72 hours may perform lap chole in acute phase

Question 8

Acute cholecystitis: Mx - empyema present

Answer 8

• High fever/RUQ mass

- Need percutaneous drainage (cholecystostomy) then lap chole

Question 9

Chronic Cholecystitis: symptoms

Answer 9

• usually vague, with unclear pathology
• Can get flatulent dyspepsia (distension, bloating, nausea, flatulence, burning)
• symptoms exacerbated by fatty foods b/c CCK release stimulates gallbladder

Question 10

Chronic Cholecystitis: differential

Answer 10

• PUD
• IBS
• Hiatus hernia
• Chronic pancreatitis

Question 11

Chronic Cholecystitis: Ix

Answer 11

• AXR: porcelain gallbladder (can see calcification within gallbladder)
• US: stones, fibrotic/shrunken gallbladder
• MRCP

Question 12

Chronic Cholecystitis: Mx - Medical and surgical

Answer 12

• Medical: bile salts (not v effective)

- Surgical: Elective cholecystectomy or ERCP first if US shows stones/dilated ducts

Question 13

Rare gallstone diseases: mucocele

Answer 13

• Neck of gallbladder blocked by stone but contents remain sterile
• Can become v large and cause palpable mass (gallbladder full of mucous)
• Can become infected and lead to empyema

Question 14

Rare gallstone diseases: gallbladder carcinoma

Answer 14

• rare
• associated with gallstones/gallbladder polyps
• Calcification of gallbladder: porcelain GB
• Incidental Ca found in 0.5-1%

Question 15

Rare gallstone diseases: Mirizzi’s syndrome

Answer 15

• rare
• large stone in GB presses on common hepatic duct causing obstructive picture/jaundice
• stone may eventually erode through into ducts

Question 16

Rare gallstone diseases: gallstone ileus (details and name of triad)

Answer 16

• Misnomer!
• Large stone (>2.5cm) erodes from GB into duodenum (cholecysto-enteric fistula secondary to chronic inflammation)
• May impact in distal ileum and cause obstruction
• Rigler’s triad: pneumobilia (gas in biliary system), SBO, gallstone in RLQ
• Rx: stone removal via enterotomy