Hepato-biliary: Gallstones, Acute cholecystitis and ascending cholangitis Flashcards
What is cholecystitis?
Inflammation of the gallbladder
What is biliary colic?
When gallbladder becomes impacted by a gallstone
What is cholangitis?
Infection of biliary tracts
What is cholithiasis?
Gallstones
What is choledocholithiasis?
Stones in the bile duct
Post cholecystectomy pain
Painful obstructive jaundice
What are the components of bile?
- Bile salts - Synthesised in liver, solubilise fat
- Lecithin - Synthesised in liver, solubilise fat
- Cholesterol - Synthesised in liver, solubilise fat
- Bile Pigments - Bilirubin (from haemoglobin)
- Toxic Metals - Detoxified in liver
- Bicarbonate - Neutralisation of acid chyme (secreted by duct cells)
- Water
How is bile pigmented?
Breakdown products of haemoglobin from old/damaged erythrocytes -> Bilirubin (predominant bile pigment)
How is bile secreted and reabsorbed?
Before secretion, bile acids are conjugated with glycine or taurine. This makes bile more soluble. Bile salts are then secreted by the following pathway:
Liver -> bile duct -> duodenum -> ileum
Secreted bile salts recycled via SMV and enterohepatic circulation
What structure controls the release of bile?
Sphincter of Oddi
What substance causes relaxation of the sphincter of oddi?
CCK
What substance causes contraction of the gallbladder?
CCK
What causes release of CCK?
Fat in the duodenum
What are the layers of the gallbladder?
- Mucosa - folded rugae -> expansion
- Muscularis - smooth muscle
- Serosa - connective tissue
Where does bile from the liver decant into when it backs up from the spinchter of oddi?
Backs up into the biliary system, and decants into the gallbladder
What determines the concentration of bile?
Length of time in the gallbladder -> more time in the gallbladder the more concentrated
What are the main types of gallstones?
- Cholesterol stones
- Pigment stones
- Mixed
What are general risk factors for the development of gallstones?
5 Fs
- Fourty
- Female
- Fat
- Fertile
- Family history
What are risk factors for the development of cholesterol gallstones?
- Obesity
- Ileal disease
- Cirrhosis
- Cystic fibrosis
- DM
- TPN
- Heart transplant
- Delayed GB emptying
- Long-term low-fat diet/rapid weight loss
- OCP - oestrogen causes more hcolestrol to be secreaed in the bile
What are risk factors associated with the development of pigment gallstones?
- Haemolytic anaemia
- Bile infection (e-coli, Bacteroides)
Composition of calcumous/cholesterol gallstones
Cholesterol + salt + biliary sludge
(linked to poor diet)
Composition of acalculous /pigment gallstones
Complication of infection/injury
Common in those with haemolytic anaemia
Pathology of gallstones
Bile is formed from choelsterol, phospholipids and bile pigments (products of haemaglobin metablolism). Gallstones form as a result of supersaturation.
What is Admirand’s triangle?
Increased risk of cholesterol stone if:
- Decreased lecithin
- Decreased bile salts
- Increased cholesterol
How can gallstones present?
Can be asymptomatic -> only symptomatic if cystic duct obstruction or passed into common bile duct (most gallstones never cause symptoms):
-
Biliary colic - associated with temporary obstruction of cystic or CBD by a stone ( no inflammatory response, contraction of gallbladdre against neck = pain)
- Reccurent episodes, colicky
- RUQ pain
- Post prandial, esp after fatty meals
- May radiate to epigastrium/back
-
Features of Complications
- Jaundice
- Acute cholecystitis
- Ascending cholangitis
- Pancreatitis
- Gallstone ileus
- Empyema/Mucocele
What is acute cholecystitis
Inflammation/infection of accumulating bile/gallbladder secondary o impacted gallstones in CD or CBD
(Inflammatory response - fever, increased WCC)
What are symptoms of acute cholecystitis?
-
Biliary colic initially - Continuous epigastric/RUQ pain -> becomes more severe, sharp pain
- Can raidaite to right shoulder
-
Local peritonism
- Can become generalised if perforation occurs
- Nausea and Vomiting
- Fever
- Muscle guarding on exam
- Persistant pain despite pain releif
Note that its the inflammatory response (fever etc) that differes from biliary colic
Where can pain from the gallbladder radiate to?
Back, right shoulder and right subscapular region
What are signs of acute cholecystitis?
- Signs of local/generalised peritonism - RUQ Tenderness, Guarding, rigidity
- Palpable tender Gallbladder
- Pyrexia
- Murphy’s Sign
- Phelgmon present
- May have jaundice
What is murphy’s sign?
As the examiner palpates the abdomen below the right subcostal margin, the patient is asked to take a deep breath in and, if on doing so, is caught by sudden pain, this is Murphy’s sign.
What is murphy’s sign a sign of?
Acute Cholecystitis
(negative for choledocholithiasis/pyelonephritis)
What is the mechanism behind murphy’s sign?
On deep inspiration the lungs expand, pushing the liver downwards so the inflamed gallbladder is pushed onto the examiner’s pressing hand, causing an unexpected sharp pain.
What is a phlegmon?
RUQ mass of inflammed adherent omentum and bowel
What are feautres of chronic cholecystitis?
Chronic inflammation +/- colic - Flatulent dyspepsia:
- Vague abdominal discomfort
- Distention
- Nausea
- Flatulence
- Fat intolerance
How can juandice occur with gallstones?
Stones travel into the common bile duct and become lodged, causing obstructive jaundice
What is acute/ascending cholangitis?
An infection of the bile duct (cholangitis), usually caused by bacteria ascending from its junction with the duodenum (first part of the small intestine). It tends to occur if the bile duct is already partially obstructed by gallstones
What is a gallstone ileus?
A stone which erodes through the gallbladder into the duodenum, which can lead to obstruction of the terminal ileum. The stone leaves a biliary enteric fistula
What is gallstone empyema?
Obstructed gallbladder fills with mucus (secreted by the GB wall) and pus
What is Mirizzi’s Syndrome?
A stone in the Gallbladder presses on the bile duct causing jaundice (extrinsic compression from impacted stone in cystic duct)
(Increased ALP, may also be caused by biliary colic)
What are complications of gallstones that can occur in the gallbladder and cystic duct?
- Biliary Colic
- Acute/Chronic cholecystitis
- Mucocele
- Empyema
- Carcinoma of gallbladder
- Mirizzi’s syndrome
What complications of gallstones can occur in the bile duct?
- Obstructive jaundice
- Acute Cholangitis
- Pancreatitis
What complications of gallstones can occur in the gut?
Gallstone ileus - fistula between gallbladder wall and duodenum causing gallstones to pass into small bowel
Bouvert: stone causes duodenal obstruction, store causes obstruction @terminal ileum
What are features of ascending cholangitis?
-
Charcot’s Triad
- RUQ pain
- Jaundice - pale stool, dark urine, pruritis, steatorrhoea
- Fever/Rigors
-
Reynold’s pentad
- Charcot’s triad plus shock and altered mental status
What is choledocholithiasis?
Denotes the presence of gallstones within the bile ducts (common hepatic duct, common bile duct)
What are features of billiary colic?
- RUQ pain -> radiates to the back and right shoulder
- Constant, crescendo characteristic
- Related to overindulgence/high fat foods
- Nausea and vomiting in severe attacks
What are features of choledocholithiasis?
Painful obstructive jaundice
- RUQ pain
-
Post-hepatic jaundice features
- Dark urine
- Pale stool
- Pruritus
- Steatorrhoea
- Features of acute pancreatitis
- Features of ascending cholangitis
What is reynold’s pentad?
Features of ascending cholangitis:
- RUQ pain
- Fever
- Jaundice
- Shock
- Altered mental status
Differentials gallstones
GORD
Peptic ulcer disease
Acute pancreatitis
IBD
What investigations would you do if you suspected someone had gallstones?
- Bloods - FBC, LFT’s, Amylase, Lipase
- Abdo US (transabdominal) FIRST LINE +/- MRCP (GOLD STANDARD)
- Consider EUS
- Consider ERCP
- Consider CT abdo
Why might you perform an FBC in someone with suspected gallstones?
Look for elevated WCC - indicative of complication such as acute cholecystitis, cholangitis or pancreatitis
Why might you perform LFTs in someone with suspect gallstones?
For biliary pain with/without jaundice - check specific aspects of function tests which may indicate cause
What might LFTs show in someone with cholelithiasis?
Normal
What is the difference between cholelithiasis and choledocholithiasis?
Cholelithiasis is the presence of solid concretions in the gallbladder. Gallstones form in the gallbladder but may exit into the bile ducts (choledocholithiasis)
When do symptoms normally occur in cholelithiasis?
When a stone obstructs the cystic, bile or pancreatic duct
What might you find on LFTs in someone with choledocholithiasis?
Obstructive pattern
- Elevated ALP and GTT
- Elevated conjugated bilirubin
- May have transiently elevated ALT
Why might you look at serum amylase and lipase in someone with suspected gallstones?
Look for signs of pancreatitis - Both elevated
What would you be looking for on Abdominal US in someone with suspected gallstones?
Look for stones in the gallbladder/sludge and echogenic shadow - best for visualisation of gallbladder.
Can also look at gallbladder wall thickness and bile duc dilation.
Can also be used to visualise choledocholithiasis, but less sensitive - may show dilated CBD
What would you be looking for abdominal ultrasound in acute cholecystitis
Pericholecystic fluid
Why might you do an MRCP in someone with suspected gallstones?- DIAGNOSTIC
For suspected choledocholithiasis that is not confirmed by Abdo US.
Can show defects in biliary tree cause by gallstone disease. Used if inconclusive US
What can MRCP show in someone with suspected gallstones?
Stones in the gallbladder or bile duct
When woudl you consider performing EUS when investigating choledocholithiasis?
- Suspected choledocholithiasis not confirmed by abdominal US - particularly in patients who cannot undergo an MRCP (claustrophobia, implanted devices)
- To confirm choledocholithiasis in high-risk patients prior to a therapeutic ERCP
When would you consider doing a CT abdo in someone with suspected gallstones?
Used to investigate suspected ascending cholangitis or gallstone pancreatitis
What are features of ascending cholangitis on CT Abdo?
Bile duct dilatation, wall thicking/outpouchings with choledocholithiasis
What non-operative interventions would you consider using to treat gallstones?
- Dissolution
- Lithotripsy
- Papillary balloon dilatation
How would you manage symptomatic cholelithiasis?
- Analgesia (typicall NASIDs/opiods)
- NBM
- Rehydrate
- Antiemetic
-
Elective Laproscopic cholecystectomy
- 6-12 weeks later when biliary tree less inflamted
- Laparoscopic and OTC goldstandard
- Complications = intra-abdominal collection, bile leak
- Abx - co-amoxiclav +/- metronidazole
How would you manage asymptomatic cholelithiasis?
Observation
How would you manage Choledocholithiasis?
With symptoms
- Analgesia
- NBM
- Rehydrate
- Antibiotics
With or without symptoms - Elective procedures:
- 1st line - ERCP with biliary sphincterectomy +/- lithotripsy/papillary balloon dilation/Long term stenting
- 2nd line - Laproscopic common bile duct exploration/cholecystectomy
How would you manage someone with acute cholecystitis?
- NBM
- Analgesia
- IV fluids
- Consider IV antibiotics
-
Laparoscopic cholecystectomy
- Preferable within 48-72 weeks due to sepsis risk
- If not suitable then percutaneous cholecystectomy - placement of drainage catheter into gallbladder then
What antibiotics would you consider using to treat someone with acute cholecystitis?
Duration 7 days
- IV amoxicillin + Gentamicin +/- Metranidazole (Co-timoxazole if penicillin allergic)
- Switch to oral Doxycycline +/- Metranidazole
If you were managing an elderly individual with acute cholecystitis, how would you manage them if they were unsuitable for laparoscopic cholecystectomy?
Percutaenous cholecystostomy with intention for later cholecystectomy
How would you manage chornic cholecystitis?
Consider ERCP + Sphincterotomy before performing definitive Cholecystectomy
How would you manage someone with Obstructive jaundice caused by CBD stones?
Consider the following
- ERCP with sphincterotomy +/- biliary trawl
- Laparoscopic exploration/Trans-hepatic exploration
- Cholecystectomy
When would you consider ITU admission in someone with acute cholecystitis?
Suspected gangre/perforation
What antibiotics would you consider giving someone with acute cholangitis?
Duration 7 days
- IV amoxicillin + Gentamicin +/- Metranidazole (Co-timoxazole if penicillin allergic)
- Switch to oral Doxycycline +/- Metranidazole
What investigations would you consider doing in someone with ascending cholangitis?
- Bloods - FBC, U+E’s, ABG, LFTs, CRP, Blood cultures, Coag screen
- Abdo ultrasound
- ERCP
- CT abdo with IV contrast
- MRCP
- Consider Trans-hepatic cholangiography
What might you find on FBC in someone with acute cholangitis?
- Increased WCC
- Decreased platelets
ESR can also be raised in acute cholecystitis
What might you find on U+Es in someone with ascending cholangitis?
- Raised urea - in severe cases
- Creatinine raised - severe cases
- Hypokalaemia
- Hypomagnasemia
Why would you consider doing an ABG in someone with suspected ascending cholangitis?
Suspicion of sepsis - may have metabolic acidosis
Why might you perform a coagulation screen on someone with features of ascending cholangitis?
Suspiciion of sepsis - May have raised PT
When would you consider ordering a MRCP in suspected ascending cholangitis??
If Abdo US and CT are negative, but still high suspicion for chlangitis
How would you mange someone with ascending cholangitis?
ABCDE - if septic
- IV antibiotics
- Analgesia - morphine, pethidine, fentanyl
-
Biliary decompression
- 1st line - ERCP + sphincterectomy + drainage stent
-
2nd line
- Choledochotomy
- Cholecystectomy + CBD exploration
What might you find on LFT in someone with ascending cholangitis?
Obstructive pattern
- Hyperbilirubinaemia - conjugated
- Raised AST/ALT
- Raised ALP
What are indications for open cholecystectomy?
- Difficult LC
- Complications during LC
- Complications of acute cholecystitis
What type of incision is performed for an open cholecystectomy?
Right subcostal incision
What are indiciations for cholecystomstomy?
Cholecystectomy deemed not to be safe
What complications can occur from a cholecystectomy?
Early
- Intra-abdominal collection
- Bile leak
- Pancreatitis
- Jaundice
- Bile duct injury
- Retained CBD stone
Late
- Biliary stricture
What are indications for surgical exploration of CBD?
CBD stones that could not be cleared by ERCP
What are indications for Biliary reconstruction?
- CBD injury
- CBD stricture
- Part of another operation
What procedure is most often used for biliary reconstruction?
Roux-en-Y Hepaticojejunostomy
What are the 5 F’s of which increase risk of gallstone formation?
- Fat
- Female
- Fair
- Fertile
- Forty
Complications of choledocholithiasis
Ascending cholangitis - Rx cefuroxime, metronidazole
CBD injury
Bile leak - peritonitis
Pancreatitis
Bleeding into biliary tree
Intra-abdominal abscess
