2: Gall Stones, Cholecystitis, Cholangiocarcinoma Flashcards by Grace Poole

What gender is most-affected by gallstones

Females (3:1)

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What are the risk factors for gallstones (5F’s)

Female

Forty

Fair

Fertile: pregnant, COCP, HRT

Fat: + malabsorption bile salts

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Where are the majority of bile salts re-absorbed

terminal ileum

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What may cause malabsorption of bile-salts

Crohn’s disease

Ileal resection

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What are pigment stones made of

Bile pigment

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What is a risk factor for pigment stones and why

Haemolytic anaemia - increases Hb degradation and hence bile produced

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How does gall stones usually present

Asymptomatic

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For individuals who develop symptoms will gallstones, what is the most common presentation

Biliary colic

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What will 35% of symptomatic individuals will gall stones develop

Acute cholecystitis

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What causes biliary colic

Impaction of neck of the gallbladder by gallstone in cystic duct - that does not cause an inflammatory response or infection

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How will biliary colic present clinically

Colicky RUQ pain. May be precipitated by consuming fatty foods. Associated with N+V

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What causes acute cholecystitis

Impaction of gallbladder by gallstone in cystic duct which causes infection/inflammation

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What sign is positive in acute cholecystitis

Murphy’s sign

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Explain Murphy’s sign

Apply pressure to RUQ - individual breathes in. If they have to stop inspiring due to pain it indicates acute cholecystitis. Only positive if negative on the left

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What cause ascending cholangitis

Obstruction of common bile duct by gallstones which then leads to infection

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What is the most common cause of ascending cholangitis

E.coli

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What are 2 other organisms, aside from E.coli, that can cause ascending cholangitis

Klebsiella

Enterococcus

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Who’s triad of symptoms presents in ascending cholangitis

Charcot’s triad

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What is charcots triad

RUQ Pain
Jaundice
Fever

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Why may patients in ascending cholangitis have pruritus

Due to accumulation of bile salts

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How will
a. stools
b. urine
present in ascending cholangitis

a. pale stools
b. dark urine
= due to an obstructive jaundice picture

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What are the symptoms of biliary colic

colicky abdominal pain

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What are the symptoms of acute cholecystitis

colicky abdominal pain

fever

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What are the symptoms of ascending cholangitis

colicky abdominal pain
fever
jaundice

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What forms bile

cholesterol, phospholipids, bile salts

Where is bile stored

Gall bladder - then released into the duodenum on stimulation

What causes gallstones

Imbalance in components of bile

What are the 3 types of gallstones

1. Cholesterol 2. Pigment 3. Mixed

What is the most common type of gallstone

Cholesterol (80%)

What are the risk factors for cholesterol gallstones (5F's)

``` Fat Female Forty Fertile Fair ```

What percentage of stones are pigment

10%

What causes pigment stones to form

Haemolytic anaemias

What causes mixed stones

Bacterial infection

What blood tests may be performed in gall stones

LFTs, FBC, Blood culture

How will FBC present in gall stones

Raised WCC in acute cholecystitis and ascending cholangitis

How will CRP present in gallstones

Raised

How will LFTs present in gallstones

Raised ALP | ± raised GGT

When are blood cultures performed

If suspecting ascending cholangitis

What is the problem with blood cultures

Only +ve in 20%

What is first-line imaging for presence gallstones

Abdominal-US

How may AUS present in gallstones

- presence gallstones - thickened GB wall - dilated biliary duct

What is gold-standard for investigating gallstones

MRCP

What is now used for diagnosis MRCP or ERCP

MRCP

When is ERCP used

If ascending cholangitis - as it is both used for investigation and management

Explain management of biliary colic

1. Analgesia (NSAIDs) 2. Risk factor reduction: exercise, diet. 3. Elective laparoscopic cholecystectomy

What time frame should an elective laparoscopy be offered

Explain management of acute cholecystitis

- Fluids - Analgesia - Antibiotics - NBM - NG Tube for medications if vomiting - Laparoscopic cholecystectomy

What antibiotics are given in acute cholecystitis

Co-amoxiclav | Metronidazole

What time frame should laparoscopic cholecystectomy be performed in acute cholecystitis

48h

How can ascending cholangitis present and what should be done in this case

Sepsis - initiate sepsis 6

How should ascending cholangitis be managed

- Fluids - Analgesia - ERCP and biliary decompression

What antibiotics are used for ascending cholangitis

co-amoxiclav and metronidazole

If patients are unfit for ERCP, what is performed

percutaneous trans-hepatic cholangiography (PTC)

What are 4 complications of ERCP

1. Pancreatitis 2. Bleeding 3. Perforation 4. Cholangitis

What are 5 complications of gall stone disease

1. Pancreatitis 2. Gallbladder empyema 3. Gallstone ileus 4. Bouveret syndrome 5. Chronic cholecystitis

What is gall bladder empyema

Collection of pus in gall-bladder, lead patients to be septic

What is chronic cholecystitis

Recurrent acute cholecystitis - can lead to inflammation

What is bouveret's syndrome

Inflammation causes fistula to form between GB and duodenum. Gall stones can pass through and cause obstruction duodenum

What is gallstone ileus

Presence large gall stones occluding terminal ileum

What is cholangiocarcinoma

Cancer arising from the

What age is cholangiocarcinoma more common

>65

In which region is cholangiocarcinoma more common and why

South East Asia. | As cholangiocarcinoma is associated with liver fluke (parasitic infection)

How can risk factors for cholangiocarcinoma be divided

Gallbladder pathology | Or, Environmental

What are 5 RFs of 'biliary tract pathology' that predispose to cholangiocarcinoma

1. History Gallstones disease (75%) 2. Primary Sclerosing Cholangitis (10%) 3. Congenital - Caroli's disease 4. Porcelain gallbladder 5. Adenoma

What is a porcelain gallbladder

Intra-mural calcification of GB wall due to chronic cholecystitis

What is caroli's disease

Congenital defect - with dilation of intra-hepatic duct

What is a risk factor for primary sclerosing cholangitis

Ulcerative colitis

What are 4 environmental factors predisposing to cholangiocarcinoma

1. Smoking, Alcohol 2. Obesity 3. Infection liver fluke 4. Chronic cholecystitis

What two infections most commonly result in chronic cholecystitis

1. H.pylori | 2. Salmonella

How will cholangiocarcinoma present clinically

Asymptomatic until late stage - where it will present with jaundice, and obstructive jaundice picture

What is the most common site of origin of cholangiocarcinoma

junction of left and right-hepatic duct

What are tumours that arise at bifurcation of hepatic ducts called

Klatskin tumour

What type of cancer are cholangiocarcinomas

adenocarcinoma

What blood-tests are ordered for cholangiocarcinoma

LFT CA19-9 CEA

What imaging is ordered for cholangiocarcinoma

AUS MRCP CT

What is gold-standard for cholangiocarcinoma

MRCP

What is used CT used for in cholangiocarcinoma

staging of cholangiocarcinoma

What staging system is used for cholangiocarcinoma

TNM

What is primary management for cholangiocarcinoma

Surgery ± adjuvant radiotherapy

If tumours are intrahepatic or klatskin, what procedure is indicated

Partial hepatectomy - with biliary tree resection

If tumours are in the distal duct what surgical procedure is indicated

Whipple's procedure

What type of treatment do the majority of individuals with cholangiocarcinoma end up receiving

Palliative - only 10-15% present at an early enough stage for surgical management

What does palliative treatment for cholangiocarcinoma involve

ERCP stenting | Palliative radiotherapy

What is the prognosis for cholangiocarcinoma

12-18m from diagnosis

2: Gall Stones, Cholecystitis, Cholangiocarcinoma Flashcards

(84 cards)