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Flashcards in Gallstone disease Deck (22)
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1

Name five risk factors for gallstone disease

'Fair, Fat, Fertile, Female, Forty'

  • Previous gallstones; FHx
  • Diet high in triglyceriders and refined carbs; low fibre
  • Obesity; NAFLD
  • Increasing age
  • Rapid weight loss: XS cholesterol in bile
  • Diabetes; Crohn's disease
  • COCP; HRT: oestrogen raises HMG-CoA reductase activity

2

Name five complications of gallstones disease

  • Biliary colic
  • Acute cholecystitis
  • Acute pancreatitis
  • Obstructive jaundice; Mirizzi syndrome
  • Ascending cholangitis
  • Fistula; Bouveret's syndrome
  • Biliary peritonitis
  • Gallbladder mucocele
  • Association with gallbladder cancer

3

Define biliary colic

Sudden pain in the epigastrium or RUQ

  • May radiate to the right inferior scapular region
  • Steady non-paroxysmal typically lasting for 30m - 8h
  • NaV

4

Differentiate biliary colic, acute cholecystitis, and cholangitis

  • Biliary colic:
    • RUQ pain
  • Acute cholecystitis:
    • RUQ pain and tenderness + fever/raised WCC
  • Cholangitis:
    • RUQ pain + fever (often rigors)/raised WCC + jaundice

5

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

Similar manoeuvre in LUQ should not elicit discomfort

6

How does chronic cholecystitis present?

  • Recurrent biliary colic (RUQ pain) and RUQ tenderness
  • Absent fever (unlike acute cholecystitis)

May not be accompanied by gallbladder inflammation

Inflammation not correlated with biliary colic intensity or frequency

7

Outline Charcot's cholangitis triad

Ascending cholangitis (50-70% present)

  1. Fever, often with rigors
  2. Jaundice
  3. RUQ abdominal pain
  • Reynold's pentad: essential surgical decompression
    • Addition of hypotension + altered mental state

8

State Reynold's pentad and its significance

  1. Fever, often with rigors
  2. Jaundice
  3. RUQ pain
  4. Mental state changes
  5. Hypotension

Suggestive of severe acute obstructive cholangitis

Surgical decompression is essential (preferably ERCP)

9

What is ascending cholangitis?

Infection of the bile duct (cholangitis) due to bacteria ascending from the ampulla of Vater. Typically involves partial obstruction.

Common organisms:

  • Klebsiella spp.
  • E. coli
  • Enterobacter spp.
  • Enterococci
  • Streptococci

10

Name three causes of cholangitis

Bacterial infection of bile duct secondary to partial blockage:

  • Gallstones
  • ERCP
  • Tumours
    • Pancreatic cancer
    • Cholangiocarcinoma
    • Ampullary cancer
    • Metastasis
  • Bile duct stricture or stenosis
  • May have parasitic infection

11

What is a gallbladder mucocele?

Gallbladder distention due to inappropriate accumulation of mucus due to outlet obstruction

12

Request three investigations for gallstone disease

  • Abdominal USS: 90-95% sensitive for gallstones
    • Common bile duct dilation (>6mm)
  • LFTs, FBC
  • Serum amylase
  • Blood cultures
  • MRCP or Endoscopic USS

13

Outline the management of asymptomatic gallstones

No treatment required if asymptomatic gallstones are found in a normal gallbladder, with a normal biliary tree

Asymptomatic gallstones are very common

Refer if located in common bile duct

14

When is gallstones disease indicated for surgery?

  • Symptomatic gallstone disease
  • Asymptomatic gallstones within the common bile duct
  • High risk of complications in gallstones disease

15

Outline the management of symptomatic gallstones

  • Adequate analgesia
    • Severe: IM diclofenac; consider opioids
    • Mild-moderate: paracetamol or NSAID
  • ERCP + laparoscopic cholecystectomy
    • Common bile duct stones
  • Laparoscopic cholecystectomy
    • Early: within 1 week of developing acute cholecystitis
  • Consider percutaneous drainage of gallbladder empyema
    • If surgery is contraindicated and conservative failed
  • Consider low-fat diet to help prevent biliary pain

16

Name three risks of laparoscopic cholecystectomy

  • Conversion to open operation
  • Bile duct injury
  • Bleeding
  • Bile leak

17

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.

Borders:

  • Superior: Inferior liver surface
  • Inferior: Cystic duct
  • Medial: Common hepatic duct

18

Outline the medical management of acute cholecystitis

  • NBM
  • Analgesia
  • IV fluids
  • Abx if appropriate

19

Outline the surgical management of acute cholecystitis

  • Laparoscopic cholecystectomy
    • Acute or delayed
    • Open cholecystectomy if perforation
  • Percutaneous cholecystostomy if high risk or unfit for surgery
    • Consider delayed cholecystectomy

20

What is the treatment of ascending cholangitis?

  • IV broad-spectrum Abx eg. Cefuroxime, Metronidazole
    • 70% recovery
  • Supportive treatment
  • Biliary drainage (preferably ERCP) if underlying obstruction
  • Consider ITU referral: high mortality (11-27%)

21

What is Courvoiser's law?

  • Palpable gallbladder in the presence of jaundice
    • Jaundice is unlikely to be due to stones
    • Cholangiocarcinoma or pancreatic head tumour
  • Stones cause thickened and fibrosed gallbladder
    • Thus not palpable

22

Name three risks of ERCP

  • Bleeding
  • Perforation of biliary tree
  • Cholangitis
  • Pancreatitis (1-3%)