L11 + 12: Gallstones, Pancreatitis & Jaundice Flashcards
What is the function of the gall bladder?
storage + concentration of bile (not vital)
Which 2 components of bile aid in digesting fats?
- Bile Salts
2. Phospholipids
List 4 components of the bile which are excreted?
- Bilirubin
- Cholesterol
- Calcium Salts
- Copper
What is cholelithiasis? (definition)
gallstones in the gall bladder
What is choledocholithiasis? (definition)
gallstones in the CBD
Gallstones are predominantly composed of what?
Cholesterol
List some of the risk factors/predisposing factors for developing gallstones
- female
- increasing age
- obesity
- diet: high fat/low fibre; high lipids
- T2DM
- high dose oestrogen (pregnancy, OCP, HRT)
- fertility
- medications (clofibrate)
- gall bladder hypomotility/stasis
- haemolytic disorders
What illness can clofibrate cause? (hint: biliary-related)
gallstones
What can cause gallbladder hypomotility/stasis?
- rapid weight loss (bariatric surgery)
- fasting
Bilirubin (pigment) gallstones are less common but they may occur. List some of the possible causes of these gallstones
- bile salt depletion (Crohn’s ileitis, ileal surgery)
- cirrhosis
- haemolysis
- parasites
Briefly describe the pathogenesis of gallstones
- altered bile composition - lithogenic bile (increased cholesterol)
- gall bladder hypomotility leading to bile stasis
List some of the symptoms of symptomatic gall stones
- biliary colic
- steady RUQ/epigastric pain
- pain >30 mins and < 4 hours
- pain may occur post-prandial (after eating due to CCK release)
- may radiate to right shoulder/back
- crescendo pattern
List 4 complications of gallstones
- Acute Cholecystitis
- Common Bile Duct Obstruction
- Mirizzi Syndrome
- Gall Bladder Adenocarcinoma
What is Mirizzi Syndrome?
extrinsic compression of the CBD by a gallstone impacted in the cystic duct/gall bladder
- stone in Hartman’s pouch
- causes obstructive jaundice
What is a porcelain gallbladder suggestive of?
Gall Bladder Adenocarcinoma
- the gall bladder becomes calcified and usually has long-standing gallstones
What is cholecystitis? (definition)
inflammation of the gall bladder
Acute cholecystitis may be a complication of gall stones if there is a…..
cystic duct obstruction
List the symptoms of acute cholecystitis
- fever*
- nausea
- vomiting
- pain in RUQ (for days)
- RUQ tenderness*
- positive Murphy’s sign*
- high WCC*
What is the treatment/management plan for acute cholecystitis?
- analgesia
- abdominal US
- ± IV empiric antibiotics
- IV fluids
- Nil Po if vomiting
- Laparoscopic Cholescystectomy*
What are the main differences in symptoms in cholelithiasis (gallstones) and acute cholecystitis (inflammation of gall bladder)?
in Acute Cholecystitis will have….
- fever
- RUQ tenderness
- high WCC
- positive Murphy’s sign
List some of the complicationso of acute cholecystitis
- necrotising inflammation + risk of perforation
- empyema (pus in gall bladder)
- mucocoele
- fistula formation + risk of gallstone ileus
- adhesions
A complication of acute cholecystitis is fistulas. What structures would the fistula form between and what is a possible consequence?
- fistula b/w gall bladder and stomach/duodenum
- gallstone ileus may occur (gall stone gets stuck in terminal ileum)
List 3 consequences of a CBD obstruction by gall stones
- Obstructive Jaundice
- Ascending Cholangitis
- Acute Pancreatitis
What is chronic cholecystitis and what is it a/w?
- always a/w gall stones
- gall bladder shows chronic response to repeated obstruction/inflammation
Describe the appearance of chronic cholecystitis
- fibrotic, shrunken gall bladder w/ stones
- thickened muscle
- atrophied mucosa
- diverticula
What are the possible treatments for gall stones?
Symptomatic - remove (cholecystectomy)
Asymptomatic - observe
What is an MRCP?
- non-invasive
- MRI scan of the liver, gallbladder, bile ducts, pancreas and pancreatic duct
How would an extrahepatic bile duct obstruction appear on ultrasound?
there will be dilated ducts above the obstruction
If there are gallstones causing an extrahepatic bile duct obstruction, what would be the treatment?
ERCP w/ sphincterotomy ± stone removal
If there is a stricture causing an extrahepatic bile duct obstruction, what would be the treatment?
stent
If there is a tumour causing an extrahepatic bile duct obstruction, what would be the treatment?
stent
What is ascending cholangitis a complication of?
blockage of a bile duct (esp. CBD)
What is Charcot’s Triad?
a/w biliary obstruction and ascending cholangitis
- High Fever
- Pain
- Jaundice
What is Reynold’s Pentad?
a/w biliary obstruction and ascending cholangitis
- High Fever
- Pain
- Jaundice
- Hypotension
- Altered Mental State
What is the treatment/management plan for ascending cholangitis?
- IV antibiotics
- IV fluids
- urgent decompression of bile duct (removal of bile and the underlying cause of the blockage)
What is the most common cause of a hepatic abscess?
biliary tract disease a/w ascending infection
Is mild or severe pancreatitis more common?
Mild Pancreatitis
Why may there be hypocalcaemia with acute pancreatitis?
- fat that gets damaged attracts calcium - these create calcium soaps (saponification)
- fat necrosis occurs
What is the treatment for acute pancreatitis caused by gall stones?
- urgent ERCP and sphincterotomy
- laparoscopic cholecystectomy when it resolves (if needed)
What is a positive murphy’s sign suggestive of?
Acute Cholecystitis
What are the histological features of chronic pancreatitis?
- patchy, irreversible fibrosis*
- ongoing inflammation
- exocrine > endocrine pancreas
- strictures
- dilatation + cysts behind strictures*
List some causes of chronic pancreatitis
- chronic alcohol use
- childhood causes (e.g CF)
- — CF more typically a/w pancreatic insufficiency
- idiopathic
List some of the symptoms of chronic pancreatitis
- pain (dull, epigastric, radiating to back)
- weight loss
- steatorrhoea (fat in the stool)
- malabsorption (b/c there is a deficiency of fat-soluble vitamins, ADEK)
List the treatments for chronic pancreatitis
- analgesia
- enzyme supplements
What is a pancreatic pseudocyst and what are some of the causes?
- collection of pancreatic fluid in disrupted tissue
- not a true cyst
Causes:
- acute/chronic pancreatitis
- pancreatic surgery
- trauma
What is another term for surgical jaundice?
obstructive jaundice
What is the most common cause of obstructive jaundice (surgical jaundice)?
GALL STONES (an extrahepatic bile duct obstruction)
List some indications for laparoscopic cholecystectomy
- symptomatic cholelithiasis (stones in gallbladder)
- cholecystitis
- porcelain gallbladder
