7.01 - HPB Gall Bladder Flashcards
(29 cards)
What is the pathophysiology of gallstones?
Bile is formed from cholesterol, phospholipids and bile pigments, and stored in the gallbladder.
Gallstones form as a result of supersaturation of bile. There are three main types of gallstones:
1) Cholesterol stones - composed purely of cholesterol, link between poor diet and obesity
2) Pigment stones - composed purely of bile pigments, from excess bile pigment production (haemolytic anaemia)
3) Mixed stones - comprised of bile pigments and cholesterol
What are the risk factors for gallstones?
5 Fs:
Female
Fat
Forty
Fertile
Family history
Pregnancy
Oral contraceptives*
Haemolytic anaemia
Malabsorption
*Oestrogen causes more cholesterol to be secreted into bile.
What is biliary colic? Give the clinical features?
Biliary colic occurs when the gallbladder neck becomes impacted by a gallstone. There is no inflammatory response, but contraction of the gallbladder (CCK) results in pain.
Pain is sudden, dull, and colicky in nature.
RUQ pain
Precipitated by consumption of fatty foods
What is acute cholecystitis? Give the clinical features.
Acute cholocystitis occures when the gallbladder neck becomes impacted by a gallstone AND there is associated inflammation.
The patient reports a constant pain in RUQ or epigastrum, with fever and lethargy.
OE tender in RUQ; Murphy +ve; ?guarding (perforation); ?sepsis
What is Murphy’s sign?
When applying pressure in RUQ, ask patient to inspire; if patient halts when inspiration this indicated inflammed gallbladder.
How are gallstones investigated?
FBC & CRP to assess for inflammatory response (cholecystitis)
LFTs - raised ALP due to ductal occlusion, but ALT and bilirubin should remain within normal limits.
Amylase to check for pancreatitis
Urinalysis, including pregnancy test, to exclude renal or tubo-ovarian pathology.
How are gallstones investigated?
FBC & CRP to assess for inflammatory response (cholecystitis)
LFTs - raised ALP due to ductal occlusion, but ALT and bilirubin should remain within normal limits.
Amylase to check for pancreatitis
Urinalysis, including pregnancy test, to exclude renal or tubo-ovarian pathology.
How are gallstones imaged?
Trans-abdominal ultrasound first line.
Magnetic Resonance CholangioPancreatography (MRCP) is gold standard if USS inconclusive.
How is biliary colic managed?
- analgesia
- lifestyle factors (weight loss, increasing exercise, low fat diet)
Elective laparoscopic cholecystectomy is definitive management.
How is acute cholecystitis managed?
- IV abx (e.g. co-amoxiclav)
- analgesia
- anti-emetics
Laparoscopic cholecystectomy within 1 week.
What is Mirizzi syndrome?
A stone located within the Hartmanns pouch or cystic duct can compress the adjacent common hepatic duct, causing obstructive jaundice.
Diagnosis confirmed via MRCP and management with laparoscopic cholocystectomy.
What is a gallbladder empyema?
Occurs when the gallbladder becomes filled with pus - pt becomes unwell, septic, and presents similar to acute cholecystitis.
Diagnosed via US or CT scan.
Treatment via laparoscopic cholocystectomy.
What is
a) Bouveret’s syndrome
b) Gallstone ileus
Inflammation of the gallbladder can cause a fistula to form between the gallbladder wall and small bowel, named a cholecystoduodenal fistula.
Gallstones can pass directly into the bowel via a cholecystoduodenal fistula, causing bowel obstruction.
a) stone impacts the proximal duodenum causing a gastric outlet obstruction.
b) stone impacts the terminal ileum, causing a small bowel obstruction.
What is cholangitis?
Infection of the biliary tract, associated with high morbidity and mortality if left untreated.
What is the pathophysiology of cholangitis?
Biliary outflow obstruction results in stasis of fluid, allowing bacterial colonisation of the biliary tree to become pathological.
What are the causes of cholangitis?
- gallstones
- cholangiocarcinoma
- pancreatitis
E. coli and Klebsiella species common causative organisms.
What are the clinical features of cholangitis?
- RUQ pain
- fever
- jaundice & pruritis
OE pyrexia, rigors, jaundice, RUQ tenderness, confusion, hypotension, tachycardia.
What is:
a) Charcot’s triad
b) Reynold’s pentad
a) jaundice, fever and RUQ pain
b) jaundice, fever, RUQ pain, hypotension and confusion
How is cholangitis differentiated from
a) biliary colic
b) cholecystitis
a) biliary colic is colicky RUQ pain without fever and jaundice.
b) cholecystitis is RUQ pain and fever, but no jaundice
Cholangitis has JAUNDICE
How is cholangitis investigated?
FBC (leucocytosis)
LFTs showing raised ALP, GGT and bilirubin
Blood cultures before empirical abx
How is cholangitis imaged?
USS of biliary tract shows bile duct dilatation.
How is cholangitis managed?
- Sepsis 6
- endoscopic biliary decompression to remove cause of blocked biliary tree
What is a cholangiocarcinoma?
Malignancy of the biliary system, most commonly an adenocarcinoma.
What are Klatskin tumours?
Most common site for bile duct cancers is at the bifurcation of the right and left hepatic ducts, termed Klatskin tumours.
They are slow-growing tumours that invade locally, before spreading distally.
