Surgical Management of the Gallbladder Flashcards
What is the cause of gallstones?
What are the risk factors?
- Derangement of biliary chemistry.
- Female sex.
- Getting older.
- Being fertile or on the oral contraceptive pill.
- Family history.
- Obesity
How do gallstones present?
- Many are asymptomatic - most people do not get abnormal LFTs.
- Biliary colic
- Biliary dyspepsia
- Acute cholecystitis
- CBD stones / jaundice
- Acute pancreatitis
- Gallstone ileus - presents with small bowel obstruction
What is gallstone ileus?
A gall stone becomes lodged in the small bowel.
Describe cholecystitis.
- A stone becomes trapped in the cystic duct.
- Bile cannot be ejected from the gallbladder and it stagnates.
- The stagnated bile irritates the gallbladder mucosa which (in response) secretes mucous and inflammatory enzymes.
- This results in distension and pressure build-up in the gall bladder.
- This is cholecystitis.
What are the characteristics of biliary colic?
- Severe pain in RUQ / epigastrium.
- Lasting minutes or hours.
- May radiate to the back or chest (? IHD).
- Often nausea or vomiting.
- Usually settles spontaneously.
- Recurrence may be associated with fat intake.
- If patients eat less fat they get fewer episodes of biliary colic and are systemically okay.
- Minimal systemic upset.
What are the symptoms and signs of acute cholecystitis?
- ? History of biliary colic.
- More presistent pain.
- RUQ tenderness (? Murphy’s sign).
- May have systemic pointers (↑ T, ↑ WBC, ↑ CRP).
- More unwell, likely to be admitted.
How should biliary colic be managed?
- Analgesia
- Low fat diet
- Elective surgery if patient is seriously troubled
- ?Stone dissolution
How should acute cholecystitis be managed?
- IV fluids
- Antibiotics
- Analgesia
- Urgent investigation
- Surgery if fit and common bile duct is clear
Which investigations should be carried out on a patient who has ? acute cholecystitis?
- LFTs, amylase (anyone with upper abdominal pain should have acute pancreatitis excluded).
- USS scan.
- ? MRCP (magnetic resonance cholangiopancreatography).
- General fitness.
How are common bile duct stones are managed?
- ERCP (Endoscopic retrograde cholangiopancreatography) for most.
- At operation (laparoscopic or open).
What are the complications of ERCP?
- Acute pancreatitis
- Bleeding
- Perforation
What are the symptoms of obstructive jaundice?
- Jaundice; itching
- Painful or painless
- Dark urine
- Pale stools
- ? Fever
What are the causes of obstructive jaundice?
- CBD stones
- Benign biliary stricture
- Intrahepatic / PBC
- Malignancy
How should obstructive jaundice be managed?
- Blood tests including liver screen.
- Imaging USS, usually followed by CT and/or MRCP.
- ERCP +/- stent, or stone removal.
- Endoscopic US +/- biopsy.
What is Charcot’s triad?
- RUQ pain and tenderness
- Obstructive jaundice
- Fever +/- rigors
How should a patient be managed if they present with Charcot’s triad?
- Medical emergency.
- IV fluids and antibiotics.
- Close monitoring on HDU.
- Biliary decompression once well enough.
- Most commonly related to common bile duct stones.
What areas can be affected by biliary malignancy?
- Bile duct
- Gall bladder
- Ampulla
- Pancreas
What are the risk factors for bile duct cancer?
- Primary sclerosing cholangitis
- Common bile duct stones
- Liver fluke infection
- Cirrhosis
- Hepatitis
What are the risk factors for pancreatic cancer?
- Age
- Smoking
- Obesity
- Diabetes
- Pancreatitis
- Gallstones or gallbladder surgery
- ? Alcohol
How is pancreatic cancer staged?
- CT
- EUS
- Biopsy if accessible
How should pancreatic cancer be managed?
- Surgery if possible
- Biliary stent
- (Bypass surgery)
What is the outlook for patients with pancreatic cancer?
- Reasonable outlook for patients with ampullary cancer (30-50% 5 year survival).
- Very poor otherwise
