Biliary colic and cholecystitis Flashcards
(32 cards)
Bilary tree
Describe the pathophysiology of gallstone disease?
- Bile is formed from choelsterol, phospholipids and bile pigments
- Stored in gallbladder before passing into the duodenum when stimulated
- Gallstones form as a result of supersaturation of bile
What are the main types of gallstones?
- Cholesterol stones
- Link between poor diet, obesity and cholesterol stones
- Pigment stones
- Seen in those with known haemolytic anaemia
- Mixed stones
- Composed of both cholesterol and bile pigments
What are the risk factors for gallstones?
- Fat
- Female
- Fertile
- Forty
- Family history
- Pregnancy, oral contraceptives, haemolytic anaemia, malasorption
What is the link between oral contraceptives and bile stones?
Oestrogen causes more cholesterol to be secreted into bile
Describe biliary colic?
- Occurs when the gallbladder neck becomes impacted by a gallstone
- No inflammatory response
- Contraction of gallbladder against occluded neck causes the pain
Describe the pain of biliary colic?
- Sudden, dull, colicky
- Right upper quadrant, can radiate to epigastrium/back
- Precipitated by the consumption of fatty foods
- May be associated with nausea and vomiting
Why does the consumption of fatty foods exacerbate biliary colic?
- Stimulate the duodenum endocrine cells to release cholecystokinin (CCK)
- CCK stimulates contraction of the gallbladder
Describe the symptoms of acute cholecystitis?
- Similar to biliary colic but the pain can be constant and continue despite pain relief
- Associated with signs of inflammation (fever, raised WCC)
- Derangement of LFTs
- Tender in RUQ with a positive Murpheys sign
What is Murpheys sign?
- Whilst applying pressure in the RUQ, ask the patient to inspire
- Murphys sign is positive when there is a halt in inspiration due to pain
- Indicates an inflamed gallbladder
Describe the investigations that should be performed with someone who has suspected gallstone disease?
- Urinalysis (including pregnancy test)
- FBC, CRP, U&Es
- LFTs (raised ALP: ductal occlusion, other LFTs will be normal)
- Amylase to exclude pancreatitis
- Imaging:
- 1st line: Transabdominal US
- 2nd line: MRCP
What can be visualised on transabdominal US to help in the diagnosis of gallstone disease?
- Presence of gallstones or sludge
- Gallbladder wall thickness
- Bile duct dilatation
Describe the use of MRCP in diagnosing gallstone disease?
- Can show defects in the biliary tree
- Near 100% sensitivity
Describe the initial management of biliary colic?
- Analgesia
- NSAIDs + PRN opioids
- Anti-emetic
- Advised about lifestyle factors:
- Low fat diet, weight loss, increased exercise
Describe the definitive management of biliary colic?
Elective cholecystectomy
Describe the initial management of Acute cholecystitis?
- IV antibiotics (co-amoxiclav +/- metronidazole)
- Fluid resuscitation
- NG tube if patient is vomiting
- Analgesia
- Antiemetics
Describe the definitive management of Acute cholecystitis?
- Laparoscopic cholecystectomy within 1 week
- Ideally within 72 hours of presentation
- If not fit for surgery/antibiotics not working
- Percutaneous cholecystectomy
Name some complications of gallstones disease?
- Gallbladder empyema
- Chronic cholecystitis
- Bouveret’s syndrome
- Gallstone ileus
- Mucocoele
Describe gallbladder empyema as a complication of gallstone disease?
- Gallbladder is infected and an abscess forms
- Patients are typically septic
- Diagnosed by US or CT
- Laproscopic cholecystectomy is the treatment
- May require conversion to open surgery
Describe chronic cholecystitis as a complication of gallstone disease?
- Recurrent/untreated cholecystitis => chronic inflammation of GB wall
- Asymptomatic or ongoing RUQ/epigastric pain
- With N/V
- Diagnosed by CT scan
- Elective cholecystectomy to treat
- Increased risk of gallbladder carcinoma and biliary-enteric fistula
Describe Bouveret’s syndrome as a complication of gallstone disease?
- Inflammation of gallbldder => fistula forms to duodenum
- Gallstones pass into the small bowel
- Stone impacts to cause duodenal obstruction
Describe Gallstone ileus as a complication of gallstone disease?
- Inflammation of gallbldder => fistula forms to duodenum
- Gallstones pass into the small bowel
- Stone impacts to cause an obstruction at the terminal ileum
Describe a mucocoele?
- Develops when the outlet of the gall bladder becomes obstructed in the absence of infection
- The imprisoned bile is absorbed but clear muus continues to be secreted into the distended gall bladder
What bacteria can commonly cause Acute cholecystitis?
- E. coli
- Klebsiella aerogenes
- Strep. faecalis
