Cholelithiasis / Cholecystitis Flashcards Preview

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Flashcards in Cholelithiasis / Cholecystitis Deck (31)
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1
Q

Epidemiology of gallstones

A

Fair, fat (BMI>30), female, forty (age >40), fertile, low fibre diet (increased cholesterol reabsorption).

2
Q

What forms gallstones?

A

Formed from constituents of bile (cholesterol, bile pigments, phospholipids).

3
Q

What determines type of stone formed?

A

Relative concentrations determine stone formed (i.e. cholesterol will only crystallise into stones when bile is supersaturated with cholesterol relative to bile and phospholipid content).

4
Q

Features of cholesterol stones?

A

Large, often solitary.

Radiolucent stones.

5
Q

Features of pigment stones?

A

Small, radiolucent.
Less common.
May be ass/w haemolytic anaemia (increased pigment from Hb).

6
Q

What is biliary colic?

A

Transient obstruction of gallbladder (cystic duct neck) due to impacted stone. Resolves when stone falls back into GB/passes into CBD.

7
Q

What is the pain of biliary colic?

A

Severe gripping pain.

  • often ass/w meals
  • maximal in epigastrium and R hypochondriac region w/ radiation to the back
  • continous over several hours (but may wax and wane in intensity); usually lasts at least 15min
8
Q

GB appearance in acute cholecystitis?

A

Thickened, inflammed, oedematous +/- gangrenous

9
Q

What is empyema of GB?

A

Unrelieved obstruction in presence of infected bile. Tender mass + rigours + marked pyrexia.

10
Q

Common organisms found in bile?

A

E. coli; Klebsiella aerogenes; Strep faecalis; Staphylococci; Clostridia; Salmonella.

11
Q

CF of acute cholecystitis?

A
  • severe pain R hypochondrium; radiation to R subscap / shoulder
  • tachycardia / pyrexia / vomiting / leukocytosis
  • marked abdo tenderness of GB
  • Murphy’s +ve
12
Q

What is Murphy’s sign?

A

Catching of breath at height of inspiration while GB is palpated.

13
Q

Ddx of acute cholecystitis?

A
  • PUD
  • High retrocaecal appendicitis
  • Acute pancreatitis
  • MI
  • Basal pneumonia
14
Q

What is chronic cholecystitis?

A

Repeated bouts of biliary colic / acute cholecystitis –> fibrosis –> contraction of GB –> chronic inflammatory change with marked wall thickening.

15
Q

Hx of chronic cholecystitis?

A

Recurrent flatulence, fatty food intolerance and RUQ pain. Pain worse after meals and ass/w feeling of distension and heart burn.

16
Q

Ddx of chronic cholecystitis?

A
  • PUD
  • Hiatus hernia
  • myocardial ischaemia
  • Chronic pancreatitis
  • GI neoplasia
17
Q

What is Couvoisier’s law?

A

Fibrosed GBs that contain stones cannot distend when pressure increases in the obstructed biliary tree. If GB palpable in presence of jaundice, jaundice unlikely to be due to stones.

18
Q

What is a mucocoele?

A

GB outlet obstruction in absence of infection. Imprisoned bile is absorbed, clear mucous continues to be secreted into distended GB.

19
Q

Presentation of mucocoele?

A

Hx of biliary colic + non-tender piriform swelling in R hypochondriac + lack of systemic upset + afebrile

20
Q

What is choledocholithiasis?

A

Gallstone in CBD

21
Q

Complications of choledocholithiasis?

A

Stones may pass spontantenously or give rise to:

  • obstructive jaundice
  • cholangitis
  • acute pancreatitis
22
Q

When do gallstones cause acute pancreatitis?

A

When small stone obstructs ampulla of Vater.

23
Q

Is choledocholithiasis generally painful?

A

NO! Little muscle in CBD wall; unless impeded flow through Sphincter of Oddi.

24
Q

Pathophysiology of choledocholithiasis?

A

Impaction at sphincter impeded bile flow: jaundice, pale stools, dark urine.
Generally lasts several days.

25
Q

What is gallstone ileum?

A

Gallstoe perforates the gallbladder; ulcerates into duodenum; passes on to obstruct the terminal ileum.
Uncommon form of intestinal obstruction.

26
Q

What is cholangitis (inc CFx)?

A

Infection of the bile ducts causing RUQ pain, jaundice, fever + rigors.

27
Q

What is Charcot’s triad?

A

Fever, jaundice, RUQ pain.

Indicates cholangitis.

28
Q

Ix in suspected biliary colic / cholecystitis?

A
  • LFT: may show cholestatic picture.
  • Prothrombin time: prolongation may occur over a longer period due to Vit K (fat soluble) malabsorption
  • Ultrasound examination may demonstrate stones in the gallbladder or bile ducts.
  • ERCP: In the presence of duct dilation or stones, endoscopic retrograde cholangiopancreatography (ERCP) is usually performed. Dx and Rx —> allows spincterotomy and removal of stones.
  • MRCP: Magentic resonance cholangiopancreatography and endoscopic ultrasound (EUS) help image biliary tree.
  • Haemolysis screen: if pigment stones suspected or found operatively.
29
Q

Mx of gallstones?

A
  • Cholecystectomy
  • Medical dissolution (ursodeoxycholic acid up to 2years)
  • Shockwave lithotripsy (limited efficacy)
  • Sphincterectomy via ERCP
  • If stones in biliary tree: (jaundice, cholangitis, pancreatitis) ==> IV ABs (prevent infection esp cholangitis).
30
Q

U/S features of gallstone?

A
  • Echogenic
  • Round
  • Mobile
  • Acoustic shadow
31
Q

Normal size of bile duct on U/S?

A