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Phase II: Periop Pt1 > Gallbladder Disorders > Flashcards

Flashcards in Gallbladder Disorders Deck (57):
1

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.

2

Name the two commonest presentations of gallstone disease

Biliary colic
Acute cholecystitis

3

Name 5 risk factors for gallstones disease

Previous gallstones

Fair, Fat, Fertile, Female, Forty

Increasing age
+ve Fhx
Rapid weight loss: XS cholesterol in bile
Loss of bile salts
Diabetes
Oral contraception

4

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.

5

Describe the clinical presentation of Gallstones disease

Up to 70% asymptomatic

Biliary colic
Acute cholecystitis

Chronic cholecystitis
Mucocele
Empyema
Pancreatitis
Obstructive jaundice

6

Describe the pathology of biliary colic due to gallstones

Gallstone impacting in the cystic duct or ampulla of Vater

7

Describe the pathology of acute cholecystitis due to gallstones

Distension or gallbladder with subsequent necrosis and ischaemia of the mucosal wall

8

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

9

Name 3 sinister signs that are suggestive of serious complications of gallstones

Fever and rigors
Hypotension
Epigastrium pain radiating to back
Dark urine
Jaundice
Murphy’s sign
Diffuse abdominal tenderness
+ve urine bile pigments on urinalysis

10

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

11

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

12

Outline the management of asymptomatic gallstones

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

13

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

14

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

15

What is the surgical treatment of choice for gallstone disease?

Laparoscopic cholecystectomy: offered within 1 week of developing acute cholecystitis

16

How should severe pain of symptomatic gallstones be managed?

Parenteral analgesic e.g. IM Diclofenac (NSAID)
Consider IM opioids

17

How should intermittent mild-moderate pain of symptomatic gallstones be managed?

Paracetamol
NSAIDs

18

Name 3 risks of laparoscopic cholecystectomy

Conversion to open operation (5-10%)
Bile duct injury (<1%)
Bleeding (2%)
Bile leak (1%)

19

How can a gallbladder empyema be managed if the patient is unfit for emergency surgery?

Percutaneous drainage of the gall bladder

20

What is a gallbladder mucocele?

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

21

Name 4 risk factors for cholecystitis

Gallstones or biliary sludge (95% of patients)
Hospitalisation for trauma or acute biliary illness (5%)

Gallstones risk factors:
Female
Increasing age
Obesity
Rapid weight loss
Crohn's disease
Hyperlipidaemia

22

Describe the presentation of acute cholecystitis

Continuous epigastric or RUQ pain (refers to shoulder)
NaV, anorexia
Fever
Local peritonism
Gallbladder mass

23

How does cholecystitis differ from biliary colic?

Cholecystitis features the additional inflammatory components: local peritonism, fever, raised WCC

24

What specific sign may be present in cholecystitis?

Murphy's sign is suggestive of acute cholecystitis

25

What investigations are used to confirm a diagnosis of acute cholecystitis?

FBC (WCC)
Abdominal USS

26

List 3 features seen on abdominal USS in acute cholecystitis

Thick-walled, shrunken gallbladder
Pericholecystic fluid
Stones
Common bile duct dilation (>6mm)

27

Outline the medical management of acute cholecystitis

NBM
Analgesia
IV fluids
ABX if appropriate

28

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

29

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

30

Name 3 complications of acute cholecystitis

Gallbladder necrosis (gangrenous cholecystitis)
Perforation of gallbladder
Biliary peritonitis
Peri-cholecystic abscess
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)

31

Define Bouveret syndrome

Gastric outlet obstruction secondary to impaction of gallstone in the duodenum due to the presence of a fistula.

32

Define Mirizzi's syndrome

Obstructive jaundice secondary to gallstone in cystic duct compressing the common hepatic or common bile duct

33

Outline the pathology of chronic cholecystitis

Repeated attacks of acute cholecystitis due to gallstones or biliary sludge

34

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

35

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

36

Outline Charcot's cholangitis triad

Ascending cholangitis (50-70% present)
I. Jaundice
II. Fever +/- rigors
III. RUQ abdominal pain

Reynold's pentad (10-20%): addition of hypotension + mental state changes -> essential surgical decompression

37

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

38

Name 5 complications of gallstones disease

In gallbladder and cystic duct:
-Biliary colic
-Acute and chronic cholecystitis
-Mucocoele
-Empyema
-Carcinoma
-Mirizzi's syndrome

In bile ducts:
-Obstructive jaundice
-Cholangitis
-Pancreatitis

In gut:
-Bouveret syndrome

39

What is the treatment of ascending cholangitis?

IV broad-spectrum ABX - e.g. Cefuroxime, Metronidazole
Supportive treatment
(70% recovery from the above)

Biliary drainage (preferably ERCP) if underlying obstructive cause
Consider ITU referral - high mortality (11-27%)

40

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.

41

What are the common causative organisms of cholangitis?

Klebsiella spp.
E. coli
Enterobacter spp.
Enterococci
Streptococci

42

Name 3 causes of cholangitis

Gallstones
ERCP
Tumours - pancreatic cancer, cholangiocarcinoma, ampullarf cancer, porta hepatis tumours, metastasis
Bile duct stricture or stenosis
Parasitic infection

43

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.

44

Describe the pathology of gallstone ileus

Gallstones migrate through fistulas and lodge in the GI tract

45

Where can gallstones lodge in the GI tract?

Ileum (60%): Terminal ileum is narrowest point
Jejunum (15%)
Stomach (15%)
Colon (5%)

46

What is the term given if gallstones lodge in the duodenum and cause gastric outlet obstruction?

Bouveret syndrome

47

How common is gallstone ileus secondary to gallstone disease?

Uncommon complication - 0.5% of cases

48

Describe the clinical presentation of gallstone ileus

Frequently nonspecific intermittent symptoms of nausea, vomiting, abdominal distension, and pain.

49

List 3 symptoms of gallstone ileus

Periumbilical colicky abdominal pain (early)
Abdominal distension
Vomiting (may be faculent) (later)
Absolute constipation (later)

50

List 3 signs of gallstone ileus

Obese
Abdomen distension
Small bowel peristalsis
Slight nonspecific abdominal tenderness
High-pitched tinkling sound on auscultation
Signs of dehydration

51

What are the characteristic features of gallstone ileus on imaging?

Abdominal X-ray or CT: Rigler's triad
-Small bowel obstruction
-Pneumobilia
-Gallstone in RIF (terminal ileum)

52

Outline the initial management of gallstone ileus

IV fluids to correct dehydration
NG tube to decompress stomach and avoid further vomiting

53

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

54

State Reynold's pentad and its significance

RUQ pain
Jaundice
Fever
Mental state changes
Hypotension

Suggestive of acute obstructive cholangitis, where surgical decompression is essential (preferably ERCP)

55

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.

Superior: Liver
Inferior: Cystic duct
Medial: Common hepatic duct

56

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.

57

Name 3 risks of ERCP

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