Week 9 - Gall Stones, Cholecystitis, Choliangitis Flashcards
List the products of heme metabolism in order…
- heme
- biliverdin
- bilirubin
- stercobilinogen (aka urobilinogen)
- stercobilin
Which enzyme converts heme into biliverdin ?
Heme oxygenase
Which enzyme converts biliverdin into bilirubin ?
Biliverdin reductase
What converts bilirubin into stercobilinogen ?
Bilirubin travels into the intestine, here bacteria remove glucuronic acid, converting it into stercobilinogen
Which sex is most at risk of gallstones ?
Females
(2x3 times higher chance than men)
What are the main risk factors for getting gallstones ?
- female sex
- older age (highest incidence in 40-mid70s)
- diet high in triglycerides and refined carbs
- diets low in fibre
- prolonged fasting or rapid weight loss
- obesity
- HRT
- diabetes
What is the most common type of gall stones in the uk ?
Cholesterol stones
What anatomical structure is contained within Calot’s Triangle?
Cystic artery
(blood supply to the gallbladder)
What are the borders of Calot’s triangle ?
- common hepatic duct
- inferior border of the liver
- cystic duct
What is the medical term for the RUQ pain due to having gallstones ?
Biliary colic pain
What bloods do you request when the patient presents with RUQ pain ?
- U+Es (renal function)
- LFTs (liver enzyme function and biliary obstruction)
- Amylase and Lipase (check for acute pancreatitis)
- FBC (look for infection or inflammation)
- CRP (look for infection or inflammation)
What is the first line investigation when gall stones are suspected ?
Trans abdominal ultrasound
What blood tests results would you expect to see in the case of gallstones ?
Pretty normal! The trans abdominal ultrasound is more likely to show the stones.
- normal inflammorty markers
- normal LFTs …
What is the scientific name for gallstones ?
Cholelithiasis
What causes gallstones ?
Imbalance between bile salts and cholesterol
What is the typical character of biliary colic pain ?
Pain on/just after eating, coming in waves
Why are LFTs normal on blood tests for patients with gallstones ?
Because the gall stones stay in the gallbladder/cystic duct, meaning the common bile duct is un-obstructed
Does bile travel via the cystic tic duct from liver to duodenum ?
No! It goes via the common hepatic/bile duct
How do you treat biliary colic pain/gallstones ?
Conservative management:
- fat free diets
- analgesia during biliary colic episodes
Surgical management:
- laparoscopic cholecystectomy (removes gall bladder and stones)
What problems can gallstones cause that would necessitate going to A&E ?
- acute cholecystitis
- acute cholangitis
- acute pancreatitis
What is acute cholecystitis ?
Acute infection of the gall bladder
What would you expect to see on the OBs and bloods for a patient with acute cholecystitis ?
- raised inflammatory markers (WCC, CRP)
- raised body temp
What amylase and lipase reading would suggest acute pancreatitis ?
Either of them raised higher than 3x the upper limit of normal
What % of patients with symptomatic gallstones disease will develop acute cholecystitis ? Why?
Up to 10%
A gall stone blocks the cystic duct causing inflammation in the gallbladder
Would LFTs show anything abnormal in the case of acute cholecystitis ?
No, because the gall stone remains in the cystic duct or gall bladder and do not obstruct the common bile duct
What would an ultrasound show in the case of acute cholecystitis?
- thick-walled gallbladder
- pericholecystic oedema
- a non-dilated/obstructed common bile duct
What is the indication if a patient with acute cholecystitis developing jaundice ?
Suggests the gallstone has fallen into the common bile duct, obstructing it
Why does obstruction of the common bile duct cause jaundice ?
Because bile and bilirubin can no longer enter the duodenum, increasing serum bilirubin conc which turns the patient yellow
Why does obstruction of the common bile duct cause pale stools ?
Because bile and bilirubin can no longer enter the duodenum, so stool becomes pale
Why does obstruction of the common bile duct cause dark urine ?
Because bile and bilirubin can no longer enter the duodenum, increasing serum bilirubin conc
increased serum bilirubin is excreted via renal filtration = dark urine
What would an ultrasound show if a gallstone was obstructing the common bile duct (CBD) ?
- Dilated CBD
- Might see the stone in the CBD
What are the 3 imagine methods to determine if there’s a stone in the common bile duct ?
- trans abdominal ultrasound (first line)
- MRCP (magnetic resonance cholangio-pancreatography) this is an upper abdominal MRI
- EUS (endoscopic ultrasound) gold standard, but invasive so not first line
Should you remove a stone that’s fallen into the common bile duct before or after a laparoscopic cholecystectomy ?
Before !!
The high pressure caused by the stone can cause a leak from the site of gallbladder amputation during the surgery
What is the initial treatment for acute cholecystitis ?
- analgesia
- antiemetics
- antibiotics
- IV fluids
- VTE prophylaxis
- nil by mouth in anticipation of surgery
What definitive management would you offer a patient with acute cholecystitis ?
Laparoscopic cholecystectomy, on this admission (not waiting list referral)
What are the risk of laparoscopic cholecystectomy ?
- General surgery risks (bleeding, infection, pain, chest and urinary infections, DVT and PE..)
- damage to common bile duct
- bile leak
- damage to surrounding structures (e.g stomach or duodenum)
- conversion from a laparoscopic procedure to an open one
Whose job is it to tell the patient the risks of surgery?
The surgeon or someone specialised who has a very good understanding of the procedure
What is Charcot’s triad for diagnosing acute cholangitis ?
- jaundice
- right upper quadrant pain
- pyrexia (fever)
What is Reynolds Pentad for diagnosing acute cholangitis ?
- jaundice
- right upper quadrant pain
- pyrexia (fever)
- mental alterations (confusion etc)
- sepsis
What investigations would you request in A&E with someone presenting with suspected acute cholangitis ?
- bloods
- erect CXR and AXR
- transabdo ultrasound to investigate causes of biliary obstruction
What blood results would you expect to find in acute cholangitis ?
- raised WCC
- high urea + creatinine
- really high ALP
- really high ALT
- really high bilirubin
- high lipase (not high enough to suggest pancreatitis)
- high CRP
- normal Hb
- normal albumin
- normal electrolytes
How would a CXR and AXR often present in acute cholangitis ?
Normal
this would discount a differential such as perforation or intestinal obstruction
What causes acute cholangitis ?
A downstream obstruction of the common bile duct, causing translocation of bacteria from the biliary system
Pressure in the system will increase due to the obstruction and this, paired with the bacteria, will result in sepsis
What are the various causes of acute cholangitis ?
- cholelithiasis = gallstones (most common)
- benign biliary structure
- sclerosis cholangitis
- malignant strictures
What are the main risk factors for acute cholangitis ?
- age
- history of gallstones, biliary strictures or sclerosis cholangitis
- previous biliary surgery that may lead to a narrowing of the bile duct
How do you treat a common bile duct stone/obstruction ?
remove the cause (e.g in the case of a stone) or relieve the obstruction using a stent (e.g in the case of a stricture)
What is a potential investigation used to image a common bile duct obstruction ?
An ERCP (endoscopic retrograde cholangiopancreatography)
What is an ERCP ?
A diagnostic procedure where an endoscope is used to identify and cannulate the Ampulla of Vater. A radio-opaque dye is injected and passes up into the CBD, common hepatic duct and pancreatic duct (retrograde). Fluoroscopy (X-rays) visualise the dye to detect any ‘filling defects’ e.g a stone or strictures
What is an advantage of using ERCP in the case of cholangitis ?
It can be used to visualise the obstruction as well as perform some therapeutic procedures…
- remove the stone
- insert a stent to reduce jaundice
- spincterotomy of sphincter of Oddi (to allow the passage of bile)
Can an ERCP be used as a therapeutic procedure for
A) cholangitis ? (gallstones in the CBD)
B) cholelithiasis ? (gallstones in gallbladder)
C) cholecystitis ? *(gallstones in the cystic duct
A) YES! it can be used for stones in the CBD
B) NO! It cannot be used for stones in the gallbladder
C) No! It cannot be used for stones in the cystic duct
Is an ERCP used as a common diagnostic method ?
NO because it comes with considerable risk of complications
Better diagnostic options:
- trans abdominal ultrasound (USS)
- MRCP (magnetic resonance cholangiopancreatography)
What is an ERCP primarily used for ?
Therapeutics in cases of cholangitis
e.g removing stones etc
What methods are most commonly used to diagnose the cause of biliary obstruction in cholangitis ?
- trans abdominal ultrasound (USS)
- MRCP (magnetic resonance cholangiopancreatography)
What are the risks of ERCP ?
- acute pancreatitis (5% risk)
- gastric/duodenal perforation
- bleeding (usually from an artery near the sphincter of Oddi)
- risks associated with sedation
