Flashcards in Gallbladder Disorders Deck (57):
What is the gallstone disease?
Presence of one or more stones in the gallbladder or biliary tree, and the symptoms and complications they may cause.
Name the two commonest presentations of gallstone disease
Name 5 risk factors for gallstones disease
Fair, Fat, Fertile, Female, Forty
Rapid weight loss: XS cholesterol in bile
Loss of bile salts
What types of stones can occur in gallstone disease?
Cholesterol stones (80%): Large, often solitary and radiolucent
Black pigment stones: Small, friable, irregular, and radiolucent
- risks factors: haemolysis and cirrhosis
Mixed stones: Faceted, containing calcium, pigment, and cholesterol. 10% radiopaque
Brown pigment stones (<5%)
- due to chronic stasis and infection, usually E. coli and Klebseilla spp.
Describe the clinical presentation of Gallstones disease
Up to 70% asymptomatic
Describe the pathology of biliary colic due to gallstones
Gallstone impacting in the cystic duct or ampulla of Vater
Describe the pathology of acute cholecystitis due to gallstones
Distension or gallbladder with subsequent necrosis and ischaemia of the mucosal wall
Define biliary colic
Sudden pain in the epigastrium or RUQ that may radiate to the right inferior scapular region.
May fluctuate or persist for 15min-24hr
NaV often accompanies the pain
Name 3 sinister signs that are suggestive of serious complications of gallstones
Fever and rigors
Epigastrium pain radiating to back
Diffuse abdominal tenderness
+ve urine bile pigments on urinalysis
What is Murphy’s sign?
Sign suggestive of acute cholecystitis
Pain and arrest of inspiration on palpation of the RUQ at costal margin when the patient inhales (occurs as inflamed gallbladder moves over fingers)
Similar manoeuvre in LUQ should not elicit discomfort
How should acute gallstone disease be investigated?
Abdominal USS* is 90-95% sensitive for stones
LFTs, FBC, U&Es, blood culture, serum amylase
MRCP or EUS may be done in secondary care if gallstones not detected by USS, but gallstones is still suspected
Outline the management of asymptomatic gallstones
No treatment required if asymptomatic gallstones are found in a normal gallbladder, with a normal biliary tree
When should gallstones disease be referred to surgery?
Symptomatic gallstone disease
Asymptomatic gallstones within the common bile duct
High risk of complications in gallstones disease
When does gallstones disease need urgent admission?
Pain cannot be managed
Patient is systemically unwell - e.g. sepsis
Complications of gallstone disease - e.g. acute cholecystitis, cholangitis, or pancreatitis
What is the surgical treatment of choice for gallstone disease?
Laparoscopic cholecystectomy: offered within 1 week of developing acute cholecystitis
How should severe pain of symptomatic gallstones be managed?
Parenteral analgesic e.g. IM Diclofenac (NSAID)
Consider IM opioids
How should intermittent mild-moderate pain of symptomatic gallstones be managed?
Name 3 risks of laparoscopic cholecystectomy
Conversion to open operation (5-10%)
Bile duct injury (<1%)
Bile leak (1%)
How can a gallbladder empyema be managed if the patient is unfit for emergency surgery?
Percutaneous drainage of the gall bladder
What is a gallbladder mucocele?
Gallbladder distention due to inappropriate accumulation of mucus due to outlet obstruction
Name 4 risk factors for cholecystitis
Gallstones or biliary sludge (95% of patients)
Hospitalisation for trauma or acute biliary illness (5%)
Gallstones risk factors:
Rapid weight loss
Describe the presentation of acute cholecystitis
Continuous epigastric or RUQ pain (refers to shoulder)
How does cholecystitis differ from biliary colic?
Cholecystitis features the additional inflammatory components: local peritonism, fever, raised WCC
What specific sign may be present in cholecystitis?
Murphy's sign is suggestive of acute cholecystitis
What investigations are used to confirm a diagnosis of acute cholecystitis?
List 3 features seen on abdominal USS in acute cholecystitis
Thick-walled, shrunken gallbladder
Common bile duct dilation (>6mm)
Outline the medical management of acute cholecystitis
ABX if appropriate
Outline the surgical management of acute cholecystitis
-Acute or delayed
Open cholecystectomy if perforation
Percutaneous cholecystostomy if high risk or unfit for surgery ➔ consider delayed cholecystectomy
Outline the management of bile duct stones
If gallbladder present ➔ laparoscopic cholecystectomy and exploration of common bile duct
If gallbladder removed ➔ Biliary sphincterotomy and endoscopic stone extraction (ERCP)
Biliary stent if unfit for surgery or irretrievable stones
Consider mechanical lithotripsy or extracorporeal shock-wave lithotripsy
Name 3 complications of acute cholecystitis
Gallbladder necrosis (gangrenous cholecystitis)
Perforation of gallbladder
Bouveret syndrome (GOO due to Fistula: gallbladder ➔ duodenum)
Mirizzi's syndrome (Gallstone in cystic duct compresses the common hepatic or common bile duct ➔ obstructive jaundice)
Define Bouveret syndrome
Gastric outlet obstruction secondary to impaction of gallstone in the duodenum due to the presence of a fistula.
Define Mirizzi's syndrome
Obstructive jaundice secondary to gallstone in cystic duct compressing the common hepatic or common bile duct
Outline the pathology of chronic cholecystitis
Repeated attacks of acute cholecystitis due to gallstones or biliary sludge
How does chronic cholecystitis present?
Recurrent biliary colic
Epigastric or RUQ tenderness
Absence of fever
May not be accompanied by gallbladder inflammation
Extent of inflammation does not correlate with biliary colic intensity or frequency
How would acute and chronic cholecystitis present differently?
Both would feature biliary colic pain and tenderness in epigastrium or RUQ.
Acute ➔ Fever
Chronic ➔ No fever
Outline Charcot's cholangitis triad
Ascending cholangitis (50-70% present)
II. Fever +/- rigors
III. RUQ abdominal pain
Reynold's pentad (10-20%): addition of hypotension + mental state changes -> essential surgical decompression
Differentiate biliary colic, acute cholecystitis, and cholangitis
Biliary colic: RUQ pain
Acute cholecystitis: RUQ pain + fever/raised WCC
Cholangitis: RUQ pain + fever/raised WCC + jaundice
Name 5 complications of gallstones disease
In gallbladder and cystic duct:
-Acute and chronic cholecystitis
In bile ducts:
What is the treatment of ascending cholangitis?
IV broad-spectrum ABX - e.g. Cefuroxime, Metronidazole
(70% recovery from the above)
Biliary drainage (preferably ERCP) if underlying obstructive cause
Consider ITU referral - high mortality (11-27%)
What is ascending cholangitis?
Infection of the bile duct (cholangitis) due to bacteria ascending from the ampulla of Vater.
Tends to occur if the bile duct is partially obstructed.
What are the common causative organisms of cholangitis?
Name 3 causes of cholangitis
Tumours - pancreatic cancer, cholangiocarcinoma, ampullarf cancer, porta hepatis tumours, metastasis
Bile duct stricture or stenosis
Define gallstone ileus
Obstruction of the bowel due to impaction of one or more gallstones. Stones usually need to be 2.5+cm in diameter.
Describe the pathology of gallstone ileus
Gallstones migrate through fistulas and lodge in the GI tract
Where can gallstones lodge in the GI tract?
Ileum (60%): Terminal ileum is narrowest point
What is the term given if gallstones lodge in the duodenum and cause gastric outlet obstruction?
How common is gallstone ileus secondary to gallstone disease?
Uncommon complication - 0.5% of cases
Describe the clinical presentation of gallstone ileus
Frequently nonspecific intermittent symptoms of nausea, vomiting, abdominal distension, and pain.
List 3 symptoms of gallstone ileus
Periumbilical colicky abdominal pain (early)
Vomiting (may be faculent) (later)
Absolute constipation (later)
List 3 signs of gallstone ileus
Small bowel peristalsis
Slight nonspecific abdominal tenderness
High-pitched tinkling sound on auscultation
Signs of dehydration
What are the characteristic features of gallstone ileus on imaging?
Abdominal X-ray or CT: Rigler's triad
-Small bowel obstruction
-Gallstone in RIF (terminal ileum)
Outline the initial management of gallstone ileus
IV fluids to correct dehydration
NG tube to decompress stomach and avoid further vomiting
Outline the surgical management of gallstone ileus
Abdominal emergency ➔ perforation
Enterolithotomy (removal of stone via surgical opening in the intestine) +/- cholecystectomy and fistula closure
Bowel resection if intestinal perforation and necrotic or non-viable
State Reynold's pentad and its significance
Mental state changes
Suggestive of acute obstructive cholangitis, where surgical decompression is essential (preferably ERCP)
What is Calot's triangle?
Anatomical zone used to define the usual path of the cystic artery, cystic duct, and common hepatic duct.
Important during a cholecystectomy so as to correctly ligate and cut the cystic artery and cystic duct.
Inferior: Cystic duct
Medial: Common hepatic duct
What is Courvoiser's law?
If the gallbladder is palpable in the presence of jaundice, then the jaundice is unlikely to be due to stones.
Stones cause the gallbladder to be thickened and fibrosed, and thus not palpable.