Abdominal Pain and Gall bladder disorders Flashcards

Question

What are conditions associated with mid abdominal to upper abdominal pain?

Answer 1

Gnawing, burning pain suggests peptic etiology: Peptic ulcer Gastritis Esophagitis Burning epigastric pain radiating to the jaw: -Peptic esophagitis Severe upper abdominal pain radiating to the back, associated with nausea and vomiting: Pancreatitis -Worsens when lying down -Improves when leaning forward

Answer 2

Gastroenteritis Irritable bowel syndrome (IBS)

Answer 3

Splenic flexure syndrome May also present as chest pain Triggered by bending over or wearing tight garments Relieved by passage of flatus Splenic infarction Pancreatitis Colonic obstruction (in patients with a competent ileocecal valve)

Answer 4

Due to supradiaphragmatic conditions with diaphragm inflammation: Pneumonia Pulmonary embolism Pleurisy Pericarditis

Answer 5

Muscle strain Appendicitis Salpingitis Diverticulitis (though more common in LLQ Less common causes: Ileitis Terminal ileitis (Crohn’s disease) Pyelonephritis Obturator hernia Carcinoma of the cecum

Answer 6

Vomiting BEFORE pain onset → Less likely to be an acute abdomen Vomiting AFTER pain onset → More concerning for an acute abdomen -Common in appendicitis -Absence of vomiting does not rule out acute abdomen

Answer 7

Light-colored, digestive juices, bile → Gastritis, cholecystitis, obstruction Undigested food → Proximal obstruction (achalasia, peptic esophagitis) Brown, faecal-smelling vomit → Bowel obstruction (mechanical/paralytic)

Answer 8

Jaundice + dark urine + pale stools → Obstructive jaundice Silver-colored stools (alternating with normal) → Carcinoma of the Ampulla of Vater

Answer 9

Constipation with small, dry stools alternating with diarrhoea → IBS Diarrhoea + constant pain in >40 y/o → referral ?cause

Answer 10

Inspection → Distention, pulsations, abnormal abdominal movements Auscultation → Listen to bowel sounds before palpation Palpation → Start away from pain, move toward tenderness Percussion → Check for tenderness, peritonitis

Answer 11

Rebound tenderness→Peritoneal irritation Pain worsens with deep inspiration/coughing→Peritonitis Rigidity, guarding, motionless posture→Severe peritonitis Absent bowel sounds→Paralytic ileus, severe peritonitis Hypotension, tachycardia, pallor, sweating→Shock due to peritonitis

Answer 12

Acute cholecystitis is the sudden inflammation of the gallbladder, usually caused by a gallstone blocking the cystic duct. This obstruction leads to bile buildup, causing gallbladder irritation, inflammation, and sometimes infection.

Answer 13

It develops in up to 10% of patients with symptomatic gallstones. In most cases (90%), it is caused by complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall. In 5% of cases, bile inspissation (due to dehydration) or bile stasis (due to trauma or severe systemic illness) can block the cystic duct, causing an acalculous cholecystitis.

Answer 14

Acute cholecystitis commonly affects adults aged 40–60, with a higher incidence in women due to hormonal risk factors for gallstones. It is more prevalent in Western and Hispanic populations, with obesity, diabetes, and rapid weight loss increasing the risk.

Answer 15

At least 90% of patients have gallstones. Occasionally, acute cholecystitis occurs in the absence of gallstones. Predisposing factors for acute acalculous cholecystitis: - starvation - total parenteral nutrition - narcotic analgesics - immobility Secondary infection with gram- negative flora occurs in most cases of acute acalculous cholecystitis.

Answer 16

Calculous cholecystitis is the most common type, caused by a gallstone blocking the cystic duct, leading to bile stasis, inflammation, and possible infection. Acalculous cholecystitis occurs without gallstones, usually in critically ill patients (e.g., sepsis, trauma, burns) due to gallbladder stasis, ischemia, and infection.

Answer 17

Fixed obstruction or passage of gallstones into the gallbladder neck or cystic duct leads to acute inflammation. Impacted gallstone traps bile, causing irritation and increased pressure. Mechanical trauma stimulates prostaglandin synthesis (PGI2, PGE2), driving inflammation. Secondary bacterial infection can occur, leading to necrosis and gallbladder perforation.

Answer 18

Pathophysiology is not well understood but is likely multifactorial. Functional cystic duct obstruction is often due to biliary sludge, dehydration, or bile stasis from trauma or systemic illness. Extrinsic compression may contribute to bile stasis. Some patients with sepsis develop direct gallbladder wall inflammation and ischemia without obstruction.

Answer 19

Mirizzi’s Syndrome is a rare complication of gallstone disease where a large gallstone becomes impacted in the cystic duct or gallbladder neck, causing compression of the common hepatic duct (CHD). This leads to bile duct obstruction and sometimes erosion, causing a fistula. Occurs in up to 10% of patients.

Answer 20

Acute cholecystitis may resolve spontaneously within 5–7 days if the impacted stone dislodges and cystic duct patency is restored. If patency is not re-established, inflammation and pressure necrosis can occur, leading to: -Mural and mucosal hemorrhagic necrosis -Suppurative cholecystitis -Gangrenous cholecystitis -Emphysematous cholecystitis

Answer 21

Pathological classification 1. Oedematous 2 to 4 days Gallbladder tissue is intact histologically, with oedema in the subserosal layer. 2. Necrotising 3 to 5 days Oedema with areas of haemorrhage and necrosis Necrosis does not involve the full thickness of the wall. 3. Suppurative 7 to 10 days WBCs present within the gallbladder wall, with areas of necrosis and suppuration Intra-wall abscesses involving the entire thickness of the wall Pericholecystic abscesses present. 4. Chronic Occurs after repeated episodes of mild attacks Mucosal atrophy and fibrosis of the gallbladder wall. 5. Emphysematous Air appears in the gallbladder wall due to infection with gas-forming anaerobes Often found in diabetic patients.

Answer 22

Severe, steady pain in the right upper quadrant (RUQ) or epigastric area Pain radiating to the right shoulder or back Fever and chills Nausea and vomiting Murphy’s sign positive (pain and inspiratory arrest when pressing on RUQ during deep breath) Jaundice (in severe or complicated cases)

Answer 23

Murphy’s sign is a clinical test for acute cholecystitis, where a positive result occurs when the patient experiences pain on deep inspiration with palpation of the right upper quadrant of the abdomen, indicating gallbladder inflammation.

Answer 24

Test to confirm inflammatory markers. Raised inflammatory markers indicate infection or inflammation of the gallbladder and are a guide to severity Signs of inflammation include: - Fever - Elevated white cell count - Elevated C-reactive protein - Elevated erythrocyte sedimentation rate

Answer 25

Ultrasound: This is the first-line imaging modality to confirm the diagnosis of acute cholecystitis. It can identify: Gallstones Gallbladder wall thickening Pericholecystic fluid (fluid around the gallbladder) Signs of inflammation If ultrasound is inconclusive, further imaging like CT scan or MRCP may be considered. Laboratory tests: Liver function tests (LFTs): Elevated levels can suggest biliary obstruction. White blood cell count (WBC): Likely elevated in the presence of infection or inflammation.

Answer 26

Initial management: Hospital admission is recommended for patients with suspected acute cholecystitis. Antibiotics should be started if there is concern about infection (e.g., Ceftriaxone or Piperacillin-tazobactam). Analgesia: Pain management is crucial, and NSAIDs or opioids may be used. Surgical intervention: Cholecystectomy (gallbladder removal) is the definitive treatment for acute cholecystitis and should ideally be performed within 72 hours of symptom onset. In some cases, percutaneous cholecystostomy (drainage of the gallbladder) may be performed if surgery is not feasible, especially in high-risk patients or those who are critically ill. Patients with severe sepsis, bile duct obstruction, or significant comorbidities should be referred to a specialist (e.g., gastroenterologist or surgeon).

Answer 27

Sepsis Identification: Always consider sepsis when there is acute deterioration in an adult with clinical evidence or strong suspicion of infection

Answer 28

Non-specific Symptoms: Sepsis may present with non-specific symptoms such as feeling acutely unwell with a normal temperature or more severe signs, including multi-organ dysfunction and shock.

Answer 29

Use tools like the National Early Warning Score 2 (NEWS2) to assess the risk of deterioration from sepsis. Apply clinical judgement and follow your institution’s local guidelines for sepsis management.

Answer 30

If you suspect sepsis, arrange for urgent review by a senior clinical decision-maker Within 30 minutes: For critically ill patients (e.g., NEWS2 score of 7+, septic shock). Within 1 hour: For severely ill patients (e.g., NEWS2 score of 5-6).

Answer 31

Sepsis Treatment: Start treatment promptly based on severity, urgency, and local protocols. In the community: For patients with suspected infection at high risk of deterioration, refer them urgently to hospital care (e.g., blue-light ambulance in the UK).

Answer 32

Complications of: cholecystitis acute pancreatitis perforated peptic ulcer emphysematous cholecystitis gangrenous cholecystitis gallbladder perforation

Answer 33

1. Palpate the right upper quadrant for tenderness and mass, which may indicate local perforation. A distended, tender gallbladder is palpable in about 30-40% of patients. 2. Assess for Murphy’s sign: Gently rest your hand along the costal margin and ask the patient to take a deep breath. Pain upon inspiration suggests cholecystitis. It’s a highly sensitive sign but has low specificity, especially in older adults. 3. Jaundice: Look for signs of jaundice, which occurs in 10% of cholecystitis cases due to biliary tract pressure from a distended gallbladder. 4. Monitor with NEWS2: Track and document: Respiratory rate, oxygen saturation (document FiO₂ or O₂ flow rate if supplemental oxygen is used), temperature, systolic blood pressure, heart rate, and level of consciousness or signs of new-onset confusion.

Answer 34

Irregular thickening of the gallbladder wall. Poor contrast enhancement of the gallbladder wall (interrupted rim sign). Increased fatty tissue density around the gallbladder. Gas in the gallbladder lumen or wall. Intraluminal structures (e.g., flap or membrane). Peri‐gallbladder abscess. These findings may be underestimated in ultrasound imaging, so advanced imaging (CT/MRI) is needed for accurate diagnosis.

Answer 35

Priority in Sepsis: The primary focus should be diagnosing and managing sepsis in patients presenting with symptoms of cholecystitis. Use CT or MRI to identify the cause if sepsis is suspected, with contrast-enhanced imaging preferred for diagnosing more severe conditions like gangrenous cholecystitis or gallbladder perforation.

Answer 36

- Pericholecystic fluid. - Distended gallbladder. - Thickened gallbladder wall (>3 mm). - Gallstones. - Positive sonographic Murphy's sign (although may be absent in gangrenous cholecystitis).

Answer 37

The 5 F's: 1. Female 2. Forty (or older) 3. Fat 4. Fertile (having had multiple pregnancies) 5. Fair (lighter skin, more common in people of European descent)

Answer 38

MRCP: If ultrasound does not detect common bile duct stones but the bile duct appears dilated or liver function tests are abnormal, request (MRCP). MRI: Thickening of the gallbladder wall (≥4 mm). Enlarged gallbladder (long axis ≥8 cm, short axis ≥4 cm). Presence of gallstones or retained debris. Fluid accumulation around the gallbladder. Linear shadows in the fatty tissue surrounding the gallbladder Endoscopic Ultrasound: Consider EUS if MRCP does not provide a clear diagnosis. EUS is particularly useful for detecting distal common bile duct stones and should be considered if MRCP is inconclusive but liver function tests are abnormal. However, EUS is invasive, so only proceed with a high level of suspicion. CT for Emphsematous Cholecystitis: Use CT imaging to diagnose emphysematous cholecystitis, where gas within the gallbladder wall is typically present.

Answer 39

Bilirubin: elevation = acute focal cholestasis in adjacent liver tissue or be due to common bile duct stones LFTs: Request liver function tests to indicate whether further imaging is required, such as MRCP. May show elevated bilirubin, alkaline phosphatase, and gamma glutamyl transferase due to acute focal cholestasis in adjacent liver tissue or due to common bile duct stones. Alanine aminotransferase can also be elevated if a stone has passed down the common bile duct, or if there is focal inflammation of the liver parenchyma in severe cholecystitis.

Answer 40

Serum lipase or amylase: Identify or exclude the presence of acute pancreatitis. Use serum lipase testing (if available) in preference to serum amylase A result >3 times the upper limit of the normal range confirms the diagnosis of acute pancreatitis in a patient with acute upper abdominal pain. Serum lipase and amylase have similar sensitivity and specificity but lipase levels remain elevated for longer (up to 14 days after symptom onset versus 5 days for amylase), providing a higher likelihood of picking up the diagnosis in patients with a delayed presentation. There are no blood tests that will specifically confirm the diagnosis of cholecystitis but they help to create a clinical picture of how unwell the patient and help to narrow down the differential diagnoses.

Answer 41

If sepsis is suspected

Answer 42

The main treatment goals are to: Manage sepsis, if suspected Provide supportive treatment to reduce the risk of progression to organ failure and/or local complications Treat the underlying cause Manage local complications. Treat patients with acute cholecystitis in hospital. Referral to ED for review by Gen Surg team Transfer patients to a specialist unit with surgeons

Answer 43

In all patients: - give analgesia - fluid resuscitation - antibiotics (if infection is suspected) (Follow local protocol / guidelines) Most patients will require surgery. - Laparoscopic cholecystectomy / percutaneous cholecystostomy / endoscopic US guided gallbladder drainage - Patients should be nil by mouth to rest the gallbladder and because of the likelihood of imminent surgery. - Recommended surgery within 72 hours up to a week (if delayed surgery) - In patients with severe cholecystitis, manage organ dysfunction in an intensive care unit prior to surgery.

Answer 44

1. Gall bladder empyema which is the most severe form and can result when cholecystitis is left to progress with concurrent bile stasis and cystic duct obstruction. It is a surgical emergency. 2. Gall bladder perforation 3. Acute cholangitis which occurs when biliary stenosis results in cholestasis and biliary infection. The stenosis/blockage may be due to benign causes such as bile duct stone or a tumour. This increases the pressure within the biliary system and flushes the micro-organisms or endotoxins from the infected bile into systemic circulation which causes a systemic inflammatory response.

Answer 45

Patients who undergo cholecystectomy should be seen within 2 weeks after discharge from hospital. Patients should be asked about presence or absence of nausea, vomiting, and abdominal pain, as well as their ability to tolerate oral intake. The wound should be reviewed for erythema, discharge, or pain any signs of jaundice should be noted; if such signs are present, the direct and indirect bilirubin level should be determined and an abdominal ultrasound ordered. In patients who have undergone percutaneous cholecystostomy, if no gallstones are present and cholangiogram showed a patent cystic duct, the tube should be removed in 6 to 8 weeks.

Answer 46

Removing the gallbladder and the contained gallstones when biliary pain starts will prevent further biliary attacks and reduce the risk of developing cholecystitis. If the gallbladder perforates, mortality is 30%. Untreated acute acalculous cholecystitis is life-threatening and is associated with up to 50% mortality.

Answer 47

Fever, Jaundice and RUQ pain. It normally suggests acute cholangitis.

Answer 48

Acute cholangitis (also called ascending cholangitis) is a bacterial infection of the biliary tree, usually due to biliary obstruction. It is a medical emergency that can lead to sepsis and requires urgent treatment.

Answer 49

Choledocholithiasis (gallstones in the bile duct) – Most common cause (85%) Biliary strictures (post-surgical, primary sclerosing cholangitis) Malignancy (pancreatic or cholangiocarcinoma) Parasitic infections (Ascaris, Clonorchis

Answer 50

Gram-negative bacteria: Escherichia coli (most common), Klebsiella, Enterobacter Gram-positive bacteria: Enterococcus Anaerobes: Bacteroides

Answer 51

Charcots's triad plus hypotension and confusion which ultimately suggest sepsis.

Answer 52

Right upper quadrant pain and tenderness High fever, rigors Jaundice Nausea and vomiting Dark urine, pale stools (suggesting biliary obstruction)

Answer 53

Confusion Hypotenuse Tachycardia Multi-organ failure

Answer 54

Imaging: Ultrasound is the first-line investigation, but MRCP is the gold standard for detecting biliary obstruction and stones. -Bile duct dilation (>6 mm), stones, sludge CT abdomen: May identify abscess, malignancy or complications Blood Tests: Raised white cell count and C-reactive protein (infection) Raised bilirubin, alkaline phosphatase, and gamma-glutamyl transferase (biliary obstruction) Mildly raised aspartate transaminase/alanine transaminase (hepatic involvement) Blood cultures may be positive in 50-70% of cases

Answer 55

1. Resuscitation with intravenous fluids 2. Broad-spectrum intravenous antibiotics as soon as possible - First-line: Piperacillin-Tazobactam (Tazocin) - Alternative (penicillin allergy): Cefuroxime + Metronidazole 3. Intravenous analgesia (paracetamol ± opioids) 4. Close monitoring for worsening sepsis

Answer 56

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone removal is the gold standard treatment. Surgery (cholecystectomy) is considered later to prevent recurrence if gallstones are the cause. Mild cases may resolve with antibiotics alone, but severe cases require urgent ERCP within 24-48 hours.

Abdominal Pain and Gall bladder disorders Flashcards

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