management of symptomatic and complicated gallstones Flashcards
what is cholelithiasis ?
gallstones in the gallbladder
what is the most common presentation of cholelithiasis ?
mostly asymptomatic
what are the types of gallstones ?
cholesterol
pigment
mixed
what are brown pigmeent stones associated with ?
related to bile stasis and infected bile
what are black pigment stones associated with ?
hemolysis
thalassemia
hereditary spherocytosis
sickle cell disease
patients with cirrhosis have a higher chance of which type of stones ?
black pigmented stones
what are cirrhosis and hemolytic disease associated with black pigment stones ?
with hemolytic diseases haem is broken down into bilirubin
with cirrhosis there is a higher concentration of unconjugated bilirubin
what is ezetimibe ?
highly selective intestinal cholesterol absorption inhibitor to prevent the formation of cholesterol gallstones
how do statins work to decrease the formation of cholesterol gallstones ?
statins competitively inhibit HMG-CoA
high levels of what hormone are. associated with cholesterol pigment formation ?
leptin
what’s the difference between cholangitis , cholecystitis and cholelithiasis ?
cholelithiasis - gallstone
cholecystitis - inflammation of the gallbladder
choledochlithiasis - CBD stone
cholangitis - inflammation of the billiary tree
what increases the risk of ascending cholangitis ?
impacted gallstone in the distal bile duct
what is the treatment of asymptomatic gall-stones ?
observe
unless :
has a porcelain bladder
has a stone larger than 2-3 cm
is a pediatric patient
is immunocompromised
law kda perform cholecystectomy
when can prophylactic cholecystectomy be performed ?
patients with diabetes
congenital hemolytic anemia
undergoing bariatric surgery ( because rapid weight loss is associated with gallstone formation )
or patients prepared for organ transplantation
what is the most common cause of acute cholecystitis ?
Impacted Gallstone in Hartmann’s Pouch
what is the difference between biliary colic and acute cholecystitis ?
biliary colic - temporary impaction
acute cholecystitis - prolonged impaction
what is the presentation of biliary colic ?
epigastric pain
withiin 4 hours
nausea and no vomitingg
no fever
no tendderness
normal leukocyte count
where is the maximum intensity of biliary colic pain ?
maximal inn the epigastrium and right hypochondrium with radiation to the back
if biliary colic does not resolve what happens ?
acute cholecystitis
what are the types of acute cholecystitis ?
acute calculous cholecystitis
acute acalculous cholecystitis
presentation of acute cholecystitis ?
right upper quadrant pain
referred to the tip of the shoulder or to the interscapular area
fever
nausea and vomitiing
how to clinically differentiate between acute cholecystitis and acute cholangitis ?
cholangitis - must have fever and must have jaundice and high inflammatory markers ar 10 times fold
cholecystitis - no fever and no jaundice
what two signs are associated with acute cholecystitis ?
Murphy’s sign
Boa’s sign - hyperesthesia at the 9th to the 11th rib posteriorly
if there is a tender mass palpable in right hypochondrium with a complaint pointing towards cholecystitis what should u keep in mind ?
empyema of the gallbladder
omental phlegmon
abscess
imaging used for cholecystitis ?
abdominal US
when should HIDA scan be used ?
acalcular cholecystitis
what is the non operative management of acute cholecystitis ?
NPO
nasogastric tube if vomiting
IV fluids
broad spectrum ab
IV analgesics
observation.
when to perform lap cholecystectomy and when do we perform operative ?
laparoscopic is the gold standard
if presented after 3 days interval cholecystectomy after 6 weeks
when should a cholecystectomy be performed in pregnant women ?
during the second trimester
when should an emergency cholecystectomy be done ?
empyema, persistent or progressing symptoms
what antibiotics should be used for empyema of the gallbladder ?
cefotaxime
ceftriaxone
what is the most serious complication of acute cholecystitis ?
cholangitis
what is the presentation of acute cholangitis and what is the etiology ?
charcot’s triad:
jaundice
RUQ pain
fever
etiology : gall bladder obstruction in the CBD
what is the presentation of acute suppurative cholangitis ?
presence of pus in the bile ducts
charcot’s triad plus hypotension and confusion
imaging for acute cholangitis ?
CBD and IHBR dilatation
MRCP
ERCP
treatmeent for acute cholangitis ?
iv fluids cultures antiibiotics
deecompressiion by ERCCP
If decompression by ERCP failed in acute cholangitis what is the next best step in management ?
PTBD
percutaneous transhepatic biliary drainage
what is gallstone ileus ?
mechanical intestinal obstruction resulting from passage of large gallstone into bowel lumen
nasogastric tube aspirate findings
bilious - lower GI bleeding
no bile - pylorus is competent and the bleeding is duodenal in origin
blood - upper GI bleeding
what can be delivered by nasogastric tube ?
lactulose + neomycin - if variceal bleeding
colon preparation - cathertex
fin a case -
gall bladder wall not thickened , this denotes ?
multiple gallstones with thickened. gall bladder due to fibrosis occurs in chronic calcular cholecystitis
what is riglers triad ?
triad of :
pneumobilia
intestinal obstruction
gallstone in a weird place
what is the pathogenesis of mucocele of the gallbladder ?
prolonged obstruction with no infection or inflammation
