GI - acute GB disease

Question 1

name for GS in GB?

Answer 1

cholelithiasis

Px as cholecystitis, colic

Question 2

rare complication where stones in the GBor cystic duct cause obstructive jaundice via extrinsic compression of the CBD?

Answer 2

Mirizzi’s syndrome

Question 3

name for GS in CBD?

Answer 3

choledocholithiasis

Px as obstructive jaundice, cholangitis, or pancreatitis

Question 4

name for GS obstructing the small bowel?

Answer 4

GS ileus

Question 5

risk factors for GS?

Answer 5

5 Fs

Fat (or rapid ↓)
Female
Forty
Fair (white)
Fertile (multi)

others, FOOD

FHx
Oral contraception
Older age
DM

Question 6

what causes pigment (not cholesterol) stones?

Answer 6

haemolysis

Question 7

risk factors for GS to become Sx?

Answer 7

smoking

parity

Question 8

Hx: patient has RUQ/epigastric pain (radiating to the back) +/- jaundice, worse after a fatty meal, +/- N+V?

Ex: pt writhing in pain but NO fever or peritonism

Answer 8

biliary colic
(obstruction in GB neck, cystic duct or CBD, no infection)

usually resolves <6hrs

Question 9

Tx biliary colic?

Answer 9

● SHORT TERM: analgesia, rehydrate, NBM

● LONG TERM: low fat diet, laparoscopic cholecystectomy (can be done as a day case) or ERCP if just CBD stones

Question 10

Ix biliary colic?

Answer 10

● initial:

• bloods (NO↑wbc)
• **abdo US
• LFTs
• **MRCP (if duct dilatation +/- abnormal LFTs)
• endoscopic US if MRCP inconclusive

● ΔΔ:

• urinalysis (pyelo)
• CXR (CAP)
• ECG (MI)

Question 11

1st line imaging for GS?

Answer 11

US

90% of GS radiolucent and therefore invisible on AXR

Question 12

Hx: patient has continuous RUQ/epigastric pain (radiating below R scapula) and V? (10% have jaundice)

Ex: fever, local peritonism, lying very still
● tender to palpation below R scapula (Boas’ sign)
● pain on inspiration when two fingers pressed on RUQ but not LUQ (Murphy’s)
● +/- palpable RUQ mass

Answer 12

acute cholecystitis
(inflammation bc GS in cystic duct or GB neck, 1/3 become infected - E.coli, Kleb)

(remember that pt writhes in biliary colic and there is no fever, peritonism, etc)

the mass is a phlegmon (inflamed omentum and bowel

Question 13

Ix acute cholecystitis?

Answer 13

● bloods:
- ↑ wbc
- ↑ CRP
- some have ↑ ALP, bili +/- gGT
● imaging:
- abdo US (thick walled, shrunken)
- MRCP (if dilated CBD, obstructive LFTs)
\+/- EUS if needed

Question 14

Tx acute cholecystitis?

Answer 14

● fluids, analgesia, Abx IV
● <1 wk laparoscopic cholecystectomy
● ERCP if CBD stones pre-op (or intra op clearance)

Question 15

complications acute cholecystitis?

Answer 15

● perforation (percutaneous cholecystectomy tube to drain)
● infarction/gangrene
● empyema
● chronic (fibrosed and shrunken GB)

Question 16

Hx: pt with previous multiple episodes of acute cholecystitis and Sx of flatulent dyspepsia, vague abdo discomfort, distension, N, and fat intolerance - ΔΔ?

how to Ix + Tx?

Answer 16

● **chronic cholecystitis
●hiatus hernia
●IBS
●PUD
●chronic pancreatitis
●tumour

Ix - US to image stones + assess CBD diameter
MRCP, Tx - cholecystectomy

Question 17

Hx: pt with RUQ pain, obstructive jaundice

Ex: rigors

Answer 17

acute/ascending cholangitis (Charcot’s triad)

- infected bile duct

Question 18

Ix cholangitis?

Answer 18

● bloods
- ↑ wbc, LFTs (bili, ALP, gGT)
● imaging
- US
- MRCP

Question 19

Tx cholangitis?

Answer 19

● Abx IC, fluids
● ERCP when stable (sphincterectomy and stone clearance/stenting)
● consider lap chole + CBD clearance as alternative

Question 20

Ix gallstone ileus?

Answer 20

AXR:

• air in CBD (pneumobilia)
• small bowel fluid levels
• a stone

Question 21

what is ERCP?

Answer 21

endoscopy with injection of radiocontrast into biliary tree and pancreas +/- sphincterectomy and stone clearance

Question 22

when is ERCP used?

Answer 22

CBD stones

cholangitis

Question 23

complications of ERCP?

Answer 23

acute pancreatitis
cholangitis
bleeding
perforation

Question 24

how to tell the difference between biliary colic, cholecystitis and cholangitis?
(wbc/fever, RUQ pain, jaundice)

Answer 24

all have RUQ pain
biliary colic has NO fever/wbc
cholecystitis has NO jaundice (only 10%)
cholangitis has rigors