17. Biliary Colic Flashcards
(30 cards)
Gall bladder Arterial supply
cystic artery, branch of right hepatic artery
Gall bladder Venous drainage
part portal, part visceral surface of the liver
Gall bladder Nervous supply
sympathetic coeliac plexus, parasympathetic vagus nerve, sensory phrenic nerve and hepatic plexus.
Biliary tract
right and left hepatic ducts → CBD → penetrates pancreas for the biliary duct with the pancreatic duct
Two sphincters involved in movement of bile:
1) Choledochal sphincter = allows bile storage
2) Sphincter of Oddi = controls secretion of BOTH bile and pancreatic juices
Biliary pain
Upper abdominal pain
Penetrating tightness
typically severe
located in the epigastrium
pathophysiological basis of biliary pain
distension of the biliary lumen
due to obstructed flow of bile
pain receptors in right phrenic nerve
supplying T5-T9
giving a central upper abdominal pain
Gallstones which obstruct the gall-bladder leads to 2 further types of pain:
- Referred right shoulder tip pain, due to dermatomes C3-C5
- Peritonism, pain throughout the abdomen, and guarding locally
Aetiological factors in development of gallstones
- ↑ cholesterol in the bile = obesity
- ↓ bile acids in bile = malabsorption
- ↑ bilirubin pigments
- ↑ stone formation from bacterial foci
- Lack of terminal ileum = Crohns + CF
Gallstones are more common in:
1) Women
2) Older age
3) Diabetes and obesity
Cause of Jaundice
Gall-stones block CBD can lead to cholestasis → conjugated hyperbilirubinaemia → presents as jaundice
Cause of Pruritus
Itch associated with jaundice → due to irritation from bilirubin
Cause of sepsis
Secondary infection of the static bile salts → “ascending cholangitis”
Cause of Shock, pain through to the back, vomiting
Pancreatitis, inflammation of the pancreas, secondary to blocked CBD, if stone is impacted at the sphincter of Oddi
Cause of Chronic weight loss
Malabsorption of fat, due to lack of bile salts in D2 Also need to consider another cause, such as pancreatic cancer causing an obstruction
Acute Pancreatitis symptoms
acute onset of persistent, severe epigastric abdominal, sometimes localised to the right upper quadrant. This can radiate to the back
Gallstone pancreatitis symptoms
pain is well localised onset of pain is rapid, reaching maximum intensity in 10 to 20 minutes 90% have associated nausea and vomiting
Pancreatitis signs:
- Abdominal tenderness
- Abdominal distension and hypoactive bowel sounds
- Jaundice
- Systemic inflammatory response
- Evidence of retroperitoneal bleeding: Cullen’s sign / Grey Turner sign)
Radiological investigations
1) Ultrasound abdomen 2) MRCP – magnetic resonance cholangio-pancreatography 3) ERCP – Endoscopic retrograde cholangio-pancreatography 4) CT abdomen
White cell count
Very raised, in keeping with SIRS
pH
Acidotic, likely metabolic, associated with SIRS from the pancreatitis. This is pretty severe.
Serum albumin
Low, reverse acute phase reactant, and reduced synthetic function of the liver
Serum bilirubin
Bilirubin moderately raised, again an obstructive marker.
Alanine aminotransferase
Raised, evidence of hepatic damage.
