The Gall Bladder

Question 1

Types of gall stones

Answer 1

Mixed stones 70-90%-> predominately cholesterol, with bile and calcium. Faceted and irregular

Cholesterol stones 20%-> large and smooth

Pigment stones-> Asian, due to haemolytic disorders

Calcium carbonate stones-> rare

Question 2

Risk factors for cholesterol gall stones

Answer 2

Age 
Female
FH
Multiparty 
Obesity 
Rapid wt loss
Diet
Drugs
Ideal disease 
DM
Acromegaly 
Liver cirrhosis 
Bilary stasis

Question 3

Biliary colic clinical features

Answer 3

Pain associated without acute and transient obstruction of the cystic duct 
Mins-30mins
Sever and constant RUQ pain and epigastrium 
Related to eating a fatty meal
Nausea and vomiting 
No fever 
Usually non tender 
Resolves spontaneously

Question 4

Billary colic investigations

Answer 4

Bloods:

• Normal WBC and CRP
• bilirubin normal

Abdo USS:
-gall stones within gall bladder 98% detected

Question 5

Billary colic management

Answer 5

Parenteral analgesia

Elective cholecystectomy if recurrent attacks

Question 6

Cholecystitis clinical features

Answer 6

Obstructed cystic duct-> bile stasis causes inflammation-> secondary bacterial infection

History of days
Severe localised RUQ pain
Tenderness and guarding
Murphy's positive-> hand in RUQ and catch on breath in 
Fever
Nausea and vomiting

Question 7

Cholecystitis investigations

Answer 7

Bloods:

• raised WBC and CRP
• slightly raised bilirubin

Abdo USS:

• gall stones within the gall bladder
• thickening of wall
• free fluid around gall bladder
• dilated ducts

Question 8

Cholecystitis management

Answer 8

Paine relief
Systematic antibiotics-> ceftriaxone and metronidazole
IV fluids
Cholestectomy

Question 9

Choleclocholithiasis definition

Answer 9

Bile duct stones
Transient Billary colic
May result in obstruction -> stagnation-> further stone formation and duct dilation
ERCP

Question 10

Acute cholangitis definition

Answer 10

Ascending bacterial infection of the Billary tree

Caused by obstruction of the Billary tree by stones and dilation

Question 11

Acute cholangitis symptoms

Answer 11

Billary colic
Fever 
Jaundice, previous fluctuant
Dark urine and pale stools
Impalpable gall bladder

Question 12

Acute cholangitis investigations

Answer 12

Raised inflam markers
Raised bilirubin
Raised ALP and GGT
Increased prothrombin time
Positive cultures 

USS dilated Billary tree

Question 13

Acute cholangitis managment

Answer 13

IV fluids and antibiotics
Drain in bile duct
Stent
Cholecystectomy

Question 14

Murpheys sign

Answer 14

Place hand bellow right costal margin and ask to breath in
Postivie-> stop/catch breath
=cholecystitis only

Question 15

Courvoisiers sign

Answer 15

Obstructive jaundice+painless palpable gall bladder=cancer

Question 16

T tube

Answer 16

Inserted in to common bile duct post op

Prevents bile stasis

Question 17

Gall stone ileus

Answer 17

Impaction of gall stone at ilelo-caecal valve

Air in Billary tree

Question 18

Common bacteria in cholecystitis

Answer 18

Gut bacteria
Anaerobes
E. coli
Klebsiella
Salmonella

Question 19

Carcinoma of the gall bladder epidemiology

Answer 19

Rare
60-89y
Females
95% associated with gall stones
m:f 3:7
FH
Smoking 
Obesity

Question 20

Carcinoma of the gall bladder symptoms

Answer 20

Malaise
Upper abdo pain
Nausea

Question 21

Carcinoma of the gall bladder prognosis

Answer 21

Poor as have commonly invaded liver at presentation

5y 2-5%

Question 22

Cholangiocarcinoma

Answer 22

Adenocarcinoma
Associated with gall stones and chronic cholecystitis
Females >70y
Liver fluke

Painless jaundice
Itching
Wt loss
Anaemia