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YEAR 3 TCD > WEEK 9 - right upper quadrant pain > Flashcards

WEEK 9 - right upper quadrant pain Flashcards

1
Q
A
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2
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3
Q

what are the common risk factors for developing gallstones?

A
  • female
  • obesity
  • prolonged fasting or rapid weight loss
  • diet high in triglycerides and refined carbohydrates
  • HRT
  • diabetes
  • increasing age
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4
Q

what is the most common type of gallstone in the UK?

A

80% of gallstones in the UK are cholesterol stones

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5
Q

what are the borders of Calot’s triangle?

A
  • cystic duct
  • common hepatic duct
  • inferior border of the liver
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6
Q

why is Calot’s triangle significant?

A

because it contains the cystic artery (blood supply to the gallbladder) which has to be identified during cholecystectomy

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7
Q

a distended gallbladder is a normal finding for someone who has been ______

A

fasting

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8
Q

what is acute cholecystitis?

A

inflammation of the gallbladder usually when a gallstone blocks the cystic duct

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9
Q

acute cholangitis is a clinical syndrome of what 3 things?

A

fever, jaundice and abdominal pain

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10
Q

Acute pancreatitis is inflammation of the pancreas commonly caused by _________ or ________

A

gallstones or alcohol

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11
Q

what would the gallbladder look like in chronic cholecystitis?

A

thickened wall due to recurrent inflammation

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12
Q

what are gallstones?

A

Gallstones (cholelithiasis) are stones that form in the gallbladder and are precipitated from an imbalance of bile slats and cholesterol.

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13
Q

What is biliary colic?

A
  • A common presentation to primary care
  • it is 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
  • there is no pain when the gallbladder is not stimulated, hence it’s intermittent nature and relationship to food
  • no infection present and therefore no clinical signs of Systemic Inflammatory Response Syndrome (SIRS) or sepsis
  • WCC and CRP normal
  • because the gallstones remain in the gallbladder and do not obstruct the Common Bile Duct (CBD), the LFTs are normal and US imaging will show a non-obstructing/non-dilated CBD
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14
Q

Biliary colic treatment

A
  • Conservative management can be trialled and consists of a fat-free diet (to stop stimulation of the gallbladder) and simple analgesia for any biliary colic episodes. For some patients, this is enough to control their symptoms to avoid surgery
  • Surgical management (laparoscopic cholecystectomy). If patients are symptomatic, they can be offered surgery to remove their gallbladder (and all their gallstones).
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15
Q

What stimulates the gallbladder in response to fatty acids and amino acids in the stomach and duodenum?

A

Cholecystokinin released from I-cells that line the duodenum

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16
Q

What lifestyle advice should be offered to a patient with biliary colic?

A

Avoid stimulating the gallbladder by encouraging a fat free diet. Simple analgesia such as paracetamol is appropriate

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17
Q

What are some complications of gallstones?

A
  • Acute cholecystitis – 1-3% of patients with symptomatic gallstones will develop an acute infection of the gallbladder (acute cholecystitis)
  • Acute cholangitis – About 50% of patients with acute cholangitis have a gallstone aetiology
  • Acute pancreatitis – Up to 70% of acute pancreatitis cases are due to gallstone disease.
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18
Q

What must lipase and amylase levels be for a diagnosis of acute pancreatitis?

A

3 times the upper limit of normal

19
Q

What is acute cholecystitis? Associated symptoms?

A

inflammation of the gallbladder usually when a gallstone blocks the cystic duct

abdominal pain, guarding and rebound tenderness, temperature and bloods showing raised inflammatory markers would suggest an acute infective or inflammatory process consistent with acute cholecystitis.

20
Q

Up to 10% of all patients with symptomatic gallstone disease will develop what? What does it result from?

A

Acute cholecystitis —

Usually results from a gallstone obstructing the cystic duct which causes inflammation of the gallbladder. The inflammatory response causes wall ischaemia and infection to ensue to cause localised peritonitis (hence a shift from colicky pain of biliary colic to a more constant pain from peritonitis)

There are clinical signs of a systemic inflammatory response and/or sepsis, with a rise in blood inflammatory markers, WCC and CRP. As the gallstones remain in the gallbladder and do not obstruct the CBD, there is no obstructive derangement of the LFTs. An US will also show a thick-walled gallbladder with pericholecystic oedema, and a non-obstructing / non-dilated CBD.

21
Q

If the gallstone continues to move out of the gallbladder, and falls into the CBD, then this can partially or completely obstruct the CBD causing _______ . Bile/bilirubin can no longer enter the duodenum therefore the stool becomes ____. The serum bilirubin concentration ________, and patient becomes visibly ________. The excess conjugated bilirubin is excreted by renal filtration (_____ urine). US imaging will show a _______ CBD and may visualise the stone itself in the CBD. It is important to visualise the entirety of the CBD on imaging to make sure a stone hasn’t been obscured by another organ or bowel gas.

A
  • Jaundice
  • pale
  • increases
  • jaundiced
  • dark
  • dilated
22
Q

What are the imaging modalities to determine if there is a stone in the CBD?

A
  1. Transabdominal Ultrasound Scan (US) is the first line investigation for CBD imaging
  2. MRCP (Magnetic Resonance Cholangio-Pancreatography) – this is an MRI scan of the upper abdomen that visualises the biliary tree and pancreatic ducts. It is non-invasive and has 85% sensitivity and 89% specificity for detecting CBD stones (slightly higher than an USS).
  3. Endoscopic Ultrasound (EUS) is the gold standard for visualising stones and other lesions in the CBD. However, it is an invasive procedure and therefore not first line
23
Q

Any CBD stones causing _____________ must be removed first prior to a laparoscopic cholecystectomy. A high biliary pressure from any obstruction can cause a bile leak from the cystic duct stump where the gallbladder is amputated during the cholecystectomy.

A

Obstructive jaundice

24
Q

Gallstones seen in a thick-walled gallbladder which is surrounded by pericholecystic fluid.

Diagnosis?

A

Acute cholecystitis

A thick-walled gallbladder indicates either acute or chronic inflammation of the gallbladder, but pericholecystic fluid (fluid around an oedematous gallbladder) is an acute finding.

25
Q

What would initial treatment of acute cholecystitis be in A&E?

A

Initial treatment would include:
- Analgesia
- Antiemetics
- Antibiotics (according to hospital guidelines)
- Fluid balance (intravenous fluids)
- Venous thromboembolism prophylaxis
- Nil by mouth, in anticipation for surgery

26
Q

What definite management could be offered for acute cholecystitis?

A
27
Q

What 3 things must be present for a diagnosis of acute cholangitis? What does Reynolds Pentad also include?

A

Right upper quadrant pain, pyrexia and jaundice

Reynolds pentad also includes mental status alterations and sepsis

28
Q

What is acute cholangitis?

A

An infection of the biliary tree caused by a downstream obstruction of the common bile duct

Translocation of bacteria from the biliary system ensues, as the biliary pressure increases due to the obstruction, resulting in sepsis (“cholangitis with sepsis”) which is a life-threatening presentation.

29
Q

What are 4 causes of acute cholangitis?

A
  • cholelithiasis = most common
  • benign biliary structure
  • sclerosing cholangitis
  • malignant strictures
30
Q

What are risk factors for acute cholangitis?

A
  • age
  • Hx of gallstones, biliary strictures or sclerosing cholangitis
  • previous biliary surgery that may lead to a narrowing of the bile duct
31
Q

How is CBD obstruction treated?

A

The principles of treating a CBD obstruction are to either remove the cause (such as a CBD stone) or relieve the obstruction using a stent (such as in the case of a stricture). This can be achieved endoscopically by an ERCP (Endoscopic Retrograde Cholangiopancreatography).

An ERCP is an Endoscopic / fluoroscopic diagnostic procedure where a side viewing endoscope is used to identify and cannulate the ampulla of Vater which opens in the second part of the duodenum. A radio-opaque dye is then injected Retrograde and passes up into the CBD, common hepatic duct and the 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).

32
Q

What is the advantage of an ERCP?

A

it can also be used to perform certain therapeutic procedures in the same procedure, such as extracting the stone using a wire basket, a sphincterotomy of the sphincter of Oddi (to better allow the passage of bile) or to insert a stent across the obstruction to relieve the jaundice.

33
Q

ERCP is not therapeutic for stones where?

A

In the gallbladder or cystic duct

34
Q

ERCP also comes with considerable risk of complications, and as such it is NOT used as a diagnostic procedure.

What are the risks of ERCP?

A
  • Acute pancreatitis (5% risk)
  • Gastric / duodenal perforation
  • Bleeding (usually from an artery near the sphincter of Oddi particularly if a sphincterotomy is performed)
  • Risks associated with the sedation required for the procedure
35
Q

What non-invasive investigations are used first to diagnose the cause of biliary obstruction before an ERCP is performed?

A

USS and MRCP

36
Q

After a diagnosis of acute cholangitis is confirmed, how would you manage this patient in A&E? What treatment would you start?

A

Initial treatment would include:
● Analgesia
● Antiemetics
● Antibiotics (according to hospital guidelines)
● Fluid balance (intravenous fluids and urinary catheter)
● Venous thromboembolism prophylaxis
● Nil by mouth, in anticipation for an ERCP

37
Q

What investigation rules out perforation?

A

Erect CXR

38
Q

_________ would be most useful to diagnose ERCP-induced acute pancreatitis.

A

Lipase

39
Q
A

Younger age

40
Q
A

Peptic ulcer disease

(Intestinal obstruction — gallstones can fistulate through the duodenum, and migrate to the ileocaecal value to cause an obstruction (gallstone ileus) )

41
Q

What is Mirizzi’s syndrome?

A

This is compression of the CBD from a gallstone in Hartmann’s pouch

42
Q
A

Biliary colic

43
Q
A

YEAR 3 TCD (15 decks)

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