Lecture 28 Flashcards
What is cholelithiasis?
Gallstones.
Gallstones are present in how many people?
10-20% of adults. 80% of gallstones are “silent”.
What are the types of gallstones?
1) Cholesterol stones - 80% of gallstones contain crystalline cholesterol monohydrate.
2) Pigment stones - Bilirubin and calcium salts. See in patients with ongoing homolysis and increase breakdown of haemoglobin producing bilirubin.
What is the pathogenesis of cholesterol stones?
Bile becomes supersaturated with cholesterol.
Conditions (stasis) favour crystal formation.
Cholesterol crystals remain in gallbladder long enough for stones to form e.g. stasis; and to increase in size.
What are the risk factors for cholelithiasis?
1) The incidence rises with age and is greater in women.
2) Estrogenic influences (oral contraceptives, pregnancy), obesity and rapid weight loss favour stone formation.
3) Gallbladder stasis favours stone formation.
4) A family history of gallstones.
5) Rare in under developed or developing societies.
What are the risk factors for pigment stones?
1) Disorders that favour the formation of bilirubin stones: chronic haemolytic syndromes and bacterial infection of the biliary tree.
2) Pigment stones are predominant in non-Western populations, because of infections and parasites.
What are the clinical consequences of gallstones?
1) May be asymptomatic (no symptoms) - 70-80% asymptomatic lifetime.
2) Symptomatic 1-3% per year:
Cholecystitis - acute/chronic.
Biliary colic - due to cholecoholithisasis.
Complications of above e.g. cholagitis, obstructive cholestasis, pancreatitis.
What is acute cholecystitis?
Acute inflammation of the gallbladder. Most cases are precipitated by gallstones. Where there is obstruction of the neck of the gallbaldder/cystic duct. Chemical irritation appears to be the major factor with bacterial infection later.
What are the clinical features of cholecystitis?
1) RUQ abdominal pain and tenderness.
2) Febrile.
3) Laboratory: neutrophil leucocytosis, raised bilirubin, ALP and GGT if stone in the common bile duct.
4) Imaging - ultrasound of gallbladder.
What is Chronic Cholecystitis?
It is a result from long-term association of gallstones and low-grade inflammation. Some cases have a history of repeated attacks of mild acute cholecystitis.
Describe the pathology of chronic cholecystitis?
The pathology is variable. The wall is thickened, and the gallbladder is often contracted but may be normal size or enlarged.
How do you manage cholecystitis?
1) Initial acute event: many settle with conservative therapy (IV fluids, pain relief) and up to 25% may require acute surgical intervention.
2) Longer term: cholecystectomy - most now laparoscopic.
What is choledocholithisais?
The presence of gallstones within the biliary tree.
What are the complications of choledocholithisasis?
1) Biliary obstruction - colicky abdominal pain.
2) Obstructive jaundice.
3) Pancreatitis.
4) Cholangitis.
What are the cancers of the biliary system?
1) Carcinoma of the gall bladder.
2) Carcinoma of the extrahepatic ducts.