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