EXAM #3: CHOLELITHIASIS AND CHOLECYSTITIS

Question 1

What is unique about the Gallbladder in terms of its anatomy?

Answer 1

Enlarges as it approaches the skin

Question 2

Where is the Gallbladder best found?

Answer 2

• Right costal margin in the mid-clavicular line
• RLQ
• Tip of right 11th rib

Question 3

What is the normal function of the gallblodder?

Answer 3

Stores and concentrates bile

Question 4

What mediates the muscular contraction and sphincter opening of the Gallbladder?

Answer 4

CCK (made in duodenum)

Question 5

Where does Gallbladder pain radiate to?

Answer 5

• Right back

- Shoulder

Question 6

Why does the Gallbladder pain radiate to the back and shoulder?

Answer 6

Viscerosomatic reflexes

Question 7

What are the risk factors for gallstone formation?

Answer 7

1) Age
2) Female
3) Family hx
4) Native American
5) Obesity
6) Multiparity
7) Rapid weight loss
8) Hemolytic disease
9) Alcohol
10) Estrogen
11) TPN
12) Cholesterol binding resins

Question 8

What are the different types of gallstones?

Answer 8

• Cholesterol-mixed
• Pigmented
• Sludge
• Single large

Question 9

What is the composition of a cholesterol-mixed gallstones?

Answer 9

• Cholesterol
• Bile salts
• Lecithin

Question 10

What is a pigmented gallstones composed of?

Answer 10

Calcium bilirubinate

Question 11

What is sludge?

Answer 11

• Mucoprotein
• Calcium bilirubinate
• Cholesterol

Question 12

What composes a single large gallstones?

Answer 12

Cholesterol

Question 13

What causes the undulating pattern of gallbladder pain seen with gallstones?

Answer 13

1) CCK induced let down

2) Stone obstructs and then FALLS back

Question 14

Where do gallstones commonly stick?

Answer 14

Common bile duct

Question 15

What are the signs and symptoms of gallstones?

Answer 15

• RUQ pain
• Worse after eating (high fat food)
• Murphy’s sign +

Question 16

What are the clinical types of cholecystitis?

Answer 16

• Acute
• Chronic
• Ascending cholangitis

Question 17

What are the signs of acute cholecystitis?

Answer 17

1) Unrelenting pain
2) Fever
3) RUQ pain
4) Ass. nausea and vomiting

Question 18

What are the signs of chronic cholecystitis?

Answer 18

Intermittent pain and well between bouts

Question 19

What is Ascending Cholangitis?

Answer 19

Infection of the small intestine ascending into the biliary tree

Question 20

What is a calculous gallstones?

Answer 20

US positive stone

Question 21

What is an acalculous stone?

Answer 21

US negative for stone but positive for:

• Thickened BW wall
• Fluid in GB fossa

Question 22

What is a positive sonographic Murphy’s Sign?

Answer 22

Murphy reproduced with US probe

Question 23

What labs can be elevated in cholecystitis?

Answer 23

• Total bilurubin

- Lipase if obstruction leads to pancreatitis

Question 24

How is cholecystitis treated?

Answer 24

1) NPO
2) Hydration
3) Pain control w/ Ketorolac

Question 25

What warrants admission with cholecystitis?

Answer 25

1) Impacted stone 2) Septic 3) Unrelenting pain 4) Mimic or uncertain

Question 26

What do you do if there is a negative US and clinical suspicion of gallstone?

Answer 26

HIDA

Question 27

What is a HIDA scan?

Answer 27

Nuclear med. functional study of the hepatobillary tree

Question 28

What are abnormal findings on a HIDA scan?

Answer 28

1) Non-filling i.e. obstruction 2) Non-emptying i.e. porcelain gallbladder 3) CCK sx.

Question 29

What are some of the medical therapies for cholecystitis?

Answer 29

1) Ursodiol--decrease cholesterol absorption 2) ESWL shock waves 3) Contact dissolution

Question 30

What are the quasi medical therapies for cholecystitis?

Answer 30

1) ERCP | 2) Transcutaneous drain

Question 31

What are the surgical procedures for cholecystitis?

Answer 31

1) Cholecystectomy | 2) ERCP

Question 32

What do you need to remember about the elderly and cholecystitis?

Answer 32

- Atypical presentation | - High mortality

Question 33

List some of the conditions that mimic cholecystitis.

Answer 33

- Acute inferior wall MI - Subdiaphragmatic abscess - RLL pneumonia - Appendicitis - Hepatitis - Pericarditis - PUD - Pancreatitis

Question 34

What are the important complications of gallstones to keep in mind?

Answer 34

1) Gallstone ileus (Gallstone-->obstruction) | 2) Gallstone pancreatitis

Question 35

What is Charcot's triad of cholangitis?

Answer 35

1) Jaundice 2) Fever 3) RUQ pain

Question 36

What should you do if patient comes to the ED with a surgical complication?

Answer 36

Call the surgeon