Right Upper Quadrant Pain Flashcards
Why is prolonged fasting or rapid weight loss a risk factor for gallstones?
Weight loss of >1.5kg per week can lead to supersaturation of bile from enhanced cholesterol mobilisation.
What is the most common type of gallstones in the UK?
Cholesterol stones (around 80% of gallstones in the UK).
What are the borders of Calot’s Triangle? (3)
The cystic duct, common hepatic duct and inferior border of the liver.
Why is Calot’s Triangle clinically significant?
It contains the cystic artery (the blood supply to the gallbladder) which has to be identified during a cholecystectomy.
How would the gallbladder appear on ultrasound in chronic cholecystitis?
The gallbladder would have a thickened wall due to recurrent inflammation.
How does acute cholangitis present?
A clinical syndrome of fever, jaundice and abdominal pain.
What is acute cholecystitis?
Inflammation of the gallbladder usually when a gallstone blocks the cystic duct.
What are gallstones (cholelithiasis)?
Stones that form in the gallbladder and are precipitated from an imbalance of bile salts and cholesterol.
What is biliary colic?
A common presentation in primary care; pain experienced as a gallstone temporarily obstructs the cystic duct as the gallbladder contracts during fat digestion, resulting in ‘colic’ pain which characteristically comes in waves.
How is the gallbladder physiologically stimulated?
Cholecystokinin, released from I-cells that line the duodenum in response to fatty acids and amino acids in the stomach and duodenum.
What are the two approaches to management available for biliary colic?
Conservative management - fat-free diet and simple analgesia for any biliary colic episodes.
Surgical management - if patients are symptomatic, they can be offered laparoscopic cholecystectomy (surgical removal of gallbladder and gallstones).
Why is morphine not an appropriate first line analgesic for biliary colic? (2)
It is disproportionately strong for first line prescription, and also causes spasm of the sphincter of Oddi which can make biliary colic pain worse.
What conditions requiring urgent treatment can gallstones cause? (3)
Acute cholecystitis (acute infection of the gallbladder)
Acute cholangitis (acute infection of the biliary tree)
Acute pancreatitis (inflammation of the pancreas)
What symptoms should a person with biliary colic be made aware of in safety netting? (3)
If they experience uncontrolled pain, fever or persistent vomiting, they should go to A&E.
What blood test result is needed to diagnose acute pancreatitis?
Lipase or amylase 3 times the upper limit of normal.
How does the pain experienced in acute cholecystitis differ from that in biliary colic?
The colicky pain in biliary colic becomes more constant pain due to peritonitis seen in acute cholecystitis.
What will an ultrasound show in acute cholecystitis? (2)
A thick-walled gallbladder with pericholecystic oedema, and a non-obstructing/non-dilated common bile duct.
What additional symptoms and clinical signs is seen if a gallstone moves out of the gallbladder and partially or completely obstructs the common bile duct (CBD)? (4)
-Jaundice, because bile/bilirubin can no longer enter the duodenum resulting in serum bilirubin conc. increasing.
-Pale stools
-Dark urine (excess conjugated bilirubin excreted by renal filtration)
-Dilated common bile duct on ultrasound
Name three imaging modalities that can be used to determine if there is a stone in the common bile duct (CBD).
-Transabdominal Ultrasound Scan (first line)
-Magnetic Resonance Cholangio-Pancreatography (MRCP) - MRI of upper abdomen
-Endoscopic Ultrasound (EBUS) = gold standard for visualising stones and other lesions in the common bile duct.
What is pericholecystic fluid?
An acute finding on ultrasound imaging - fluid around an oedematous gallbladder.
What is Charcot’s triad?
The combination of fever, right upper quadrant pain and jaundice - indicative of cholangitis.
What is Reynold’s Pentad?
The presence of hypotension and confusion alongside the features of Charcot’s Triad.
What is acute cholangitis?
An infection of the biliary tree caused by downstream obstruction of the common bile duct; translocation of bacteria from the biliary system ensues (as biliary pressure increases due to the obstruction) resulting in sepsis.
What are four causes of acute cholangitis?
Cholelithiasis (most common)
Benign biliary structure
Sclerosing cholangitis
Malignant structures
What two approaches can be used to treat a common bile duct (CBD) obstruction?
Removing the cause of the obstruction (such as CBD stone)
Relieving the obstruction using a stent (such as in the case of a stricture)
What is an Endoscopic Retrograde Cholangiopancreatography (ERCP)?
An Endoscopic/fluoroscopic diagnostic procedure where a side viewing endoscope is used to identify and cannulate the ampulla of Vater (which opens into second part of duodenum) - radio-opaque dye is then injected Retrograde and passes into CBD, common hepatic duct and pancreatic duct. Fluoroscopy (x-rays) are used to visualise the dye to detect any ‘filling defects’ that could indicate either a stone or a stricture (CholangioPancreatography).
What therapeutic procedures can be performed during an ERCP? (3)
Extracting the stone
A sphincterotomy of Sphincter of Oddi (to allow better passage of bile)
Insertion of stent across obstruction to relieve jaundice
What is ERCP not therapeutic for?
Stones in the gallbladder or cystic duct.
What are the main risks of ERCP? (4)
Acute pancreatitis (5% risk)
Gastric/duodenal perforation
Bleeding (particularly if sphincterotomy is performed)
Risks associated with sedation required for procedure
What investigation would help rule out visceral perforation?
An erect chest x-ray.
What are the distinguishing symptoms of biliary colic, cholecystitis and cholangitis?
Biliary Colic - has only right upper quadrant pain.
Cholecystitis - has right upper quadrant pain and fever.
Cholangitis - has right upper quadrant pain, fever and jaundice.
What are the possible causes of pancreatitis? (11)
Idiopathic
Gallstones
Ethanol (alcohol)
Trauma
Steroids
Mumps/malignancy
Autoimmune disease
Scorpion sting
Hypertriglyceridaemia/hypercalcaemia
ERCP (endoscopic retrograde cholangiopancreatography)
Drugs
[I GET SMASHED]
What are the typical symptoms of pancreatitis? (3)
Epigastric pain (severe, sudden onset, may radiate to back).
Nausea and vomiting
Decreased appetite
How can a diagnosis of acute pancreatitis be made? (3)
Two of the following three criteria must be satisfied:
-Abdominal pain plus a history suggestive of acute pancreatitis
-Serum amylase/lipase of over three times the upper limit of normal.
-Imaging findings characteristic of acute pancreatitis
Which out of lipase and amylase is more sensitive in identifying patients with acute pancreatitis?
Lipase
