Gallbladder Disorders

Question 1

Types of Gallstones
- made of what
- Risk Factors

Answer 1

majority of gallstones are made of cholesterol
- can be pigmented stones, if not cholesterol
1. black stones = hemolyiss, cirrhosis
2. brown stones = asain pop, infections

Risk Factors for Stones five f’s
- Female
- Fat
- Forty
- Fertile
- flatulence

other risks…
- genetics
- pregnancy (change in gallbaldder components & altered emptying)
- OCP use due to increase in estrogen
- IBD (malabsorbtion)
- TPN (malabsorption- no absorpbtion)
- rapid weight loss/gastric bypass

Question 2

Choelithiasis
- etiology
- symptoms
- diagnosis
- treatment

Answer 2

Etiology
- gall bladder stones within the gallbladder

Symptoms
- asymptomatic (gallbladder colic)
- can be incidental finding

Diagnosis
- US is test of choice
- can CT/MRI and see it too

Treatment
- observation
- if symptomatic: elective cholycysectomy because of risk of complications

Question 3

Biliary Colic
Etiology
Symptoms
Diagnosis
Treatment

Answer 3

Etiology
- stones within the gallbladder temporarily block or get stuck in the cystic duct; then get released and bounce back into the gallbladder
- when pt. has stones –> east fatty meal triggers cile release & the pain comes and goes

Symptoms
- sudden, episodic onset of pain in the URQ
- dull pain: radiation to the back/shoulder
- N/V, sweating
- atypical symptoms = belching, early satiety, regurg, bloating, burning

Diagnosis
- normal labs: if elevated white = think acute cholycystitis
- rise and fall of LFTs and bilirubin
imaging = to see stones
- HIDA scan to r/o others
- EGD with bile acid aspiration (crystals)

Treatment
- pain control (ketorlac), NSAIDS
- recurrent is likely –> may elect for a cholycysectomy if possible

Question 4

Acute Cholecyctitis
Etiology
Symptoms
Diagnosis
Treatment

Answer 4

Etiology
- a stone within the cystic duct obstructs, causing inflammation and possible infection behind the obstruction
- most commonly e. coli ; klebsiella second
- could also be infectious process AIDS pt = CMV or a vasculitis infection

Symptoms
- RUQ pain: CONTINUOUS & assocaited with fatty foods
- N/V
- fever (lowe grade)
- + Murphys Sign: stopping inspiration when you press on the RUQ at the gallbladder
- BOAS Sign: radaition of pain to the scapula due to phrenic nerve

Diagnosis
- initial test = US
- findings = thickened GB wall > 3mm
- CT can be done, Xray too
- Labs = leukocytosis, LFTs increased, increase bilirubin
- GOLD STANDARD: HIDA scan : where the dye will not be visable in the GB due to the obstruction

Treatment
- admit & fluids & pain management
- ABX: ceftriaxone & metronidazole
- laproscopic cholycyscectomy withn 72 hours
- visulalize the calot traingle
- non-operatable = percut. drainage of cholecystosomy

Question 5

Choledocholithiasis
Etiology
Symptoms
Diagnosis
Treatment

Answer 5

Etiology
- a gallstone which wiggles down and gets stuck within the commoon BILE duct –> creating a ductal dilation
- dilation = > 6mm
- Primary: the stone forms due to biliary stasis
- Secondary: the stone passed from the gallbladder to the common bile duct and got stuck (more common)

Symptoms
- biliary colic RUQ tenderness
- jaundice
- can be asymptomatic (50%)

Diagnosis
- initial test = US = but does not r/o
- GOLD STANDARD = ERCP: allows visulization and removal

Treatment
-ERCP: remove the stone
- then in same hopsital stay –> remove the gallbladder to stop recurrance

Question 6

Complications of cholidocholithiasis

Answer 6

• acute pancreatits! (stone blocks the pancreas too)

Symptoms
- boring epigastric pain
- use Atlanta criteria to dx.
- abd. pain
- serum amylase/lipase > 3x NL
- imagins

• acute cholangitis

Question 7

Acute cholangitis (ascending cholangitis)
Etiology
Symptoms
Diagnosis
Treatment

Answer 7

Etiology
- a biliar tract infection of the common bile duct, secondary to the infection spreading from the duodenum
- usually associated with a stone present in the bile duct causing obstruction aka stasis = increase infection

Symptoms
- charcot’s triad = RUQ pain, fever & jaundice
- Renyonds pentad = RUQ pain, fever, jaundice, shock, AMS = endoscopic emergency

Diangosis
- can use Tokyo guidlines: two of charots + labs of inflammation + elevated liver enzymes + imagins = dx.

Labs
- see Alk. phos increased (get GGT to confirm from liver)
- AST/ALT increased
- leukocytosis

US
- dilated common bile duct

GOLD STANDARD = CHOLANGIOGRAPHY: done via ERCP or PCT

Treatment
- ABX: pip-taz. based treatment
- community acquire, low risk = piptaz or ceftriaxone/metronidazole
- community acquired high risk OR in-patient = piptaz or cefipime/mentronidazole

then bild duct decompression or stone extraction via ERCP

Question 8

Acute Acalculous cholecycstits
etiology
symptoms

Answer 8

Etiology
- inflammation without the prescence of a stone
- ICU/criticall ill pts. and post op. pt.
- due to billary sludge
- think burn pts., TPN, DM, sepsis

Symptoms
- fever
- RUQ pain
- within 2-4 weeks of surgery or illness without PO intake

Question 9

Chronic Cholecystitis
etiology
two types

Answer 9

Etiology
- repeated bouts of acute/subacute cholecystits (obstructed cystic duct of stone causing infection)

Strawberry Gallbladder = cholesterol aggregation inside the GB

porcelain Gallbladder : a PREMALIGNANT conditions due to calification of the walls
- bluish color
- due to chronic inflammation

Question 10

s/p cholecystectomy

Answer 10

Complications
- bleeding
- abscess
- bile leak
- billary injury
- bowel injury

diarrhea afterwards is common and resolves

increased risk of Colon cancer (Right) , esophageal cancer and SB cancer - due to increated bile concentration, refulx, etc.