Right Upper Quadrant Pain

Question 1

Why is prolonged fasting or rapid weight loss a risk factor for gallstones?

Answer 1

Weight loss of >1.5kg per week can lead to supersaturation of bile from enhanced cholesterol mobilisation.

Question 2

What is the most common type of gallstones in the UK?

Answer 2

Cholesterol stones (around 80% of gallstones in the UK).

Question 3

What are the borders of Calot’s Triangle? (3)

Answer 3

The cystic duct, common hepatic duct and inferior border of the liver.

Question 4

Why is Calot’s Triangle clinically significant?

Answer 4

It contains the cystic artery (the blood supply to the gallbladder) which has to be identified during a cholecystectomy.

Question 5

How would the gallbladder appear on ultrasound in chronic cholecystitis?

Answer 5

The gallbladder would have a thickened wall due to recurrent inflammation.

Question 6

How does acute cholangitis present?

Answer 6

A clinical syndrome of fever, jaundice and abdominal pain.

Question 7

What is acute cholecystitis?

Answer 7

Inflammation of the gallbladder usually when a gallstone blocks the cystic duct.

Question 8

What are gallstones (cholelithiasis)?

Answer 8

Stones that form in the gallbladder and are precipitated from an imbalance of bile salts and cholesterol.

Question 9

What is biliary colic?

Answer 9

A common presentation in primary care; pain experienced as a gallstone temporarily obstructs the cystic duct as the gallbladder contracts during fat digestion, resulting in ‘colic’ pain which characteristically comes in waves.

Question 10

How is the gallbladder physiologically stimulated?

Answer 10

Cholecystokinin, released from I-cells that line the duodenum in response to fatty acids and amino acids in the stomach and duodenum.

Question 11

What are the two approaches to management available for biliary colic?

Answer 11

Conservative management - fat-free diet and simple analgesia for any biliary colic episodes.
Surgical management - if patients are symptomatic, they can be offered laparoscopic cholecystectomy (surgical removal of gallbladder and gallstones).

Question 12

Why is morphine not an appropriate first line analgesic for biliary colic? (2)

Answer 12

It is disproportionately strong for first line prescription, and also causes spasm of the sphincter of Oddi which can make biliary colic pain worse.

Question 13

What conditions requiring urgent treatment can gallstones cause? (3)

Answer 13

Acute cholecystitis (acute infection of the gallbladder)
Acute cholangitis (acute infection of the biliary tree)
Acute pancreatitis (inflammation of the pancreas)

Question 14

What symptoms should a person with biliary colic be made aware of in safety netting? (3)

Answer 14

If they experience uncontrolled pain, fever or persistent vomiting, they should go to A&E.

Question 15

What blood test result is needed to diagnose acute pancreatitis?

Answer 15

Lipase or amylase 3 times the upper limit of normal.

Question 16

How does the pain experienced in acute cholecystitis differ from that in biliary colic?

Answer 16

The colicky pain in biliary colic becomes more constant pain due to peritonitis seen in acute cholecystitis.

Question 17

What will an ultrasound show in acute cholecystitis? (2)

Answer 17

A thick-walled gallbladder with pericholecystic oedema, and a non-obstructing/non-dilated common bile duct.

Question 18

What additional symptoms and clinical signs is seen if a gallstone moves out of the gallbladder and partially or completely obstructs the common bile duct (CBD)? (4)

Answer 18

-Jaundice, because bile/bilirubin can no longer enter the duodenum resulting in serum bilirubin conc. increasing.
-Pale stools
-Dark urine (excess conjugated bilirubin excreted by renal filtration)
-Dilated common bile duct on ultrasound

Question 19

Name three imaging modalities that can be used to determine if there is a stone in the common bile duct (CBD).

Answer 19

-Transabdominal Ultrasound Scan (first line)
-Magnetic Resonance Cholangio-Pancreatography (MRCP) - MRI of upper abdomen
-Endoscopic Ultrasound (EBUS) = gold standard for visualising stones and other lesions in the common bile duct.

Question 20

What is pericholecystic fluid?

Answer 20

An acute finding on ultrasound imaging - fluid around an oedematous gallbladder.

Question 21

What is Charcot’s triad?

Answer 21

The combination of fever, right upper quadrant pain and jaundice - indicative of cholangitis.

Question 22

What is Reynold’s Pentad?

Answer 22

The presence of hypotension and confusion alongside the features of Charcot’s Triad.

Question 23

What is acute cholangitis?

Answer 23

An infection of the biliary tree caused by downstream obstruction of the common bile duct; translocation of bacteria from the biliary system ensues (as biliary pressure increases due to the obstruction) resulting in sepsis.

Question 24

What are four causes of acute cholangitis?

Answer 24

Cholelithiasis (most common)
Benign biliary structure
Sclerosing cholangitis
Malignant structures

Question 25

What two approaches can be used to treat a common bile duct (CBD) obstruction?

Answer 25

Removing the cause of the obstruction (such as CBD stone)
Relieving the obstruction using a stent (such as in the case of a stricture)

Question 26

What is an Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Answer 26

An Endoscopic/fluoroscopic diagnostic procedure where a side viewing endoscope is used to identify and cannulate the ampulla of Vater (which opens into second part of duodenum) - radio-opaque dye is then injected Retrograde and passes into CBD, common hepatic duct and pancreatic duct. Fluoroscopy (x-rays) are used to visualise the dye to detect any ‘filling defects’ that could indicate either a stone or a stricture (CholangioPancreatography).

Question 27

What therapeutic procedures can be performed during an ERCP? (3)

Answer 27

Extracting the stone
A sphincterotomy of Sphincter of Oddi (to allow better passage of bile)
Insertion of stent across obstruction to relieve jaundice

Question 28

What is ERCP not therapeutic for?

Answer 28

Stones in the gallbladder or cystic duct.

Question 29

What are the main risks of ERCP? (4)

Answer 29

Acute pancreatitis (5% risk)
Gastric/duodenal perforation
Bleeding (particularly if sphincterotomy is performed)
Risks associated with sedation required for procedure

Question 30

What investigation would help rule out visceral perforation?

Answer 30

An erect chest x-ray.

Question 31

What are the distinguishing symptoms of biliary colic, cholecystitis and cholangitis?

Answer 31

Biliary Colic - has only right upper quadrant pain.
Cholecystitis - has right upper quadrant pain and fever.
Cholangitis - has right upper quadrant pain, fever and jaundice.

Question 32

What are the possible causes of pancreatitis? (11)

Answer 32

Idiopathic
Gallstones
Ethanol (alcohol)
Trauma
Steroids
Mumps/malignancy
Autoimmune disease
Scorpion sting
Hypertriglyceridaemia/hypercalcaemia
ERCP (endoscopic retrograde cholangiopancreatography)
Drugs

[I GET SMASHED]

Question 33

What are the typical symptoms of pancreatitis? (3)

Answer 33

Epigastric pain (severe, sudden onset, may radiate to back).
Nausea and vomiting
Decreased appetite

Question 34

How can a diagnosis of acute pancreatitis be made? (3)

Answer 34

Two of the following three criteria must be satisfied:
-Abdominal pain plus a history suggestive of acute pancreatitis
-Serum amylase/lipase of over three times the upper limit of normal.
-Imaging findings characteristic of acute pancreatitis

Question 35

Which out of lipase and amylase is more sensitive in identifying patients with acute pancreatitis?

Answer 35

Lipase