what a gall(bladder)

Question 1

what are the different types of gallstones and how do they form

Answer 1

cholesterol stones - when there is too much cholesterol and the salts can’t hold it in solution any more OR because there is a limited number of bile salts so they can’t contain it OR due to gallbladder stasis
bilirubin stones - pigmented, due to too much bilirubin combining with calcium forming a precipitation - calcium bilirubinate (UCB)
brown stones - sign of infection, mix of UCB and phospholipids, common in Asian populations

Question 2

what are risk factors for gallstones

how do gallstones present

Answer 2

Asian - brown
female/contraception - cholesterol
four Fs : female fat forty fertile

Severe, colicky epigastric or RUQ pain
Triggered by meals (particularly high fat meals)
Lasting 30 minutes - 8 hours
May have nausea and vomiting
jaundice 
acute cholecystitis 
pancreatitis 
cholangitis (bile duct inflammation)

Question 3

what are investigations and management for gallstones

Answer 3

LFTs - bilirubin if obstruction, raised ALP, ALT, AST
US
MRCP
ERCP

conservative if asymptomatic
lithotripsy
dissolution
gallbladder removal (cholecystectomy) if symptomatic- stones irritate the gallbladder and increase the risk of cancer

Question 4

what is primary sclerosing cholangitis and what is primary biliary cholangitis

Answer 4

PSC - progressive cholestasis with bile duct inflammation and strictures
PBC - autoimmune attack of interlobular bile ducts causing inflammation leading to fibrosis, cirrhosis, portal hypertension

Question 5

what are risk factors for primary sclerosing cholangitis

Answer 5

male 
30-40 years 
ulcerative colitis 
chron's
HLA

Question 6

how does primary sclerosing cholangitis present

Answer 6

RUQ pain
hepatosplenomegaly
pruritis

Question 7

what investigations could you do for primary sclerosing cholangitis

Answer 7

ERCP
MRCP
biopsy
bloods - increased ALT, increased conjugated bilirubin
anti-mitochondrial antibodies in serum in PBC

Question 8

how could you treat primary sclerosing cholangitis

Answer 8

liver transplant

Question 9

what are complications of primary sclerosing cholangitis

Answer 9

cirrhosis

Question 10

what is ascending cholangitis

Answer 10

blockage in the common bile duct due to a gallstone

allows bacteria to travel up and infect

Question 11

how does ascending cholangitis present

Answer 11

jaundice
fever
RUQ pain

Question 12

what bacteria is commonly involved in ascending cholangitis

Answer 12

e.coli
enterococcus
klebsiella

Question 13

how could you investigate ascending cholangitis

Answer 13

ERCP

bloods - raised CRP etc

Question 14

how could you treat ascending cholangitis

Answer 14

rehydration
antibiotics
remove obstruction - ERCP to suction it out or shockwave lithotripsy to break down stone
stenting to widen ducts
can remove gallbladder to prevent further problems

Question 15

what are complications of ascending cholangitis

Answer 15

septic shock

Question 16

what is acute cholecystitis

Answer 16

gallstone becomes lodged in the cystic duct and causes inflammation of the gallbladder
the inflammation generates more fluids causing pressure to build up and worsen the situation
the stone usually falls back into place
if it doesn’t pressure builds until the gallbladder is compressing it’s arterial supply - ischaemia and rupture

Question 17

how does acute cholecystitis

Answer 17

mid-epigastic pain (due to gallbladder contracting) that radiates to epigastrium, shoulders and scapula
nausea 
vomiting 
rebound tenderness 
murphy's sign - pain on breathing in 
sharp pain if ruptures

Question 18

what investigations could you do for acute cholecystitis

Answer 18

bloods - increased CB and ALP indicates liver involvement
US - gallbladder thickening, distention, sludge, stones
ERCP

Question 19

how could you treat cholecystitis

Answer 19

cholecystectomy

Question 20

what are complications of cholecystitis

Answer 20

sepsis
rupture
bile can back up into liver and enter the blood stream

Question 21

what is chronic cholecystitis

Answer 21

repeated inflammation of the gallbladder due to stones constantly getting stuck and then dislodged in the cystic duct

Question 22

how does chronic cholecystitis present

Answer 22

mid-epigastic to RUQ to scapula pain
usually comes in bouts lasting about a month 
pain after meals 
nausea 
vomiting 
anorexia 
jaundice 
murphy's sign 
rebound tenderness

Question 23

a

Answer 23

a

Question 24

-

Answer 24

-

Question 25

what are complications of chronic cholecystitis

Answer 25

cancer - the epithelial wall of the gallbladder is constantly becoming inflamed and damaged putting it at a higher risk of cancer

Question 26

what are types of gallbladder cancer

Answer 26

adenocarcinoma
cholangiocarcinoma
most are extrahepatic

Question 27

what are risk factors for gallbladder cancer

Answer 27

repeated inflammation - acute cholecystitis

Question 28

how could you treat gallbladder cancer

Answer 28

cholecystectomy - only curative option
chemo
stents
radio