Biliary colic + Cholecystitis Flashcards
If thinking cholecystitis but need to think about other GI conditions, what to check for on exam?
- Jaundice - sclera first
- Cullen and Grey turners sign - retroperitoneal bleeding
- AAA - pulsatile mass?
- Murphys sign - palpate below rib in RUQ, ask patient to take deep breath in, if catches breath = +ve as gall bladder hits hand when moves down on inspiration
- Distended - obstruction?
- Lieing still - peritonitis?
Anatomy of bile ducts
Indications for surgery for gallstones
- Biliary colic - EC within 6 weeks of first presentation
- Cholecytsitis - within 1 week of presentation BUT better if within 72hrs
- Cholangitis - ERCP
- Mirizzi syndrome - LC
- Gallbladder empyema - LC
- Chronic cholecystitis - elective
EC = elective cholecystectomy, LC - laparascopic cholecystectomy
Pathophys of gallstones
- Cholesterol, phospholipids and bile pigments = bile
- Gallstones form due to supersaturation of bile
- Can be cholesterol stones, pigment stones or mixed
- Cholesterol = excess so poor diet, obesity
- Pigment = excess bile pigment seen in haemolytic anaemia
RF for gallstones
5 F’s
* Female
* Fat
* Fertile
* Forty
* FH
* Others inc pregnancy, oral contraceptives, haemolytic anaemia and malabsorption (eg Crohns or ileal resection)
OC - oestrogen increases cholesterol secretion into bile
Biliary colic
- Gallbladder neck impacted by stone
- No inflammatory response
- Contraction of gallbladder = pain
- Sudden, dull and colicky
- Precipitated by fatty foods (CCK released as fatty acids stimulate duodenum to release)
Imagine it floating and then getting trapped in neck when GB contracts
Acute cholecystitis presentation
- Constant pain RUQ
- Signs of inflammation eg fever/lethargy
- Can have +ve Murphys sign and tender RUQ
Bloods for biliary colic and cholecystitis
- FBC and CRP - inflammatory response?
- LFTs - raised ALP?
- Amylase/lipase - pancreatitis?
- Urinalysis inc pregnancy test
Imaging for biliary colic/cholecystitis suspect
- Trans-abdominal USS - FIRST LINE
- If inconclusive, can do MRCP - defects in biliary tree
What does trans-abdominal USS scan show if gallstone disease present?
- Presence of gallstones or sludge (start of GS)
- Gall bladder wall thickening - if inflammation
- Bile duct dilatation - if stone present distally
Biliary colic management
- Analgesia - paracetamol, +/- NSAIDs +/- opiates
- Weight loss, low fat, increase exercise
- Elective laparascopic cholecystectomy - within 6 weeks of first presentation
Acute cholecystitis management
- IV abx eg co-amoxiclav +/- metronidazole
- Analgesia and antiemetics
- Laparascopic cholecystectomy within 1 week BUT ideally within 72hrs of presentation
Acute cholecystitis surgery if not suitable for LC and not responding to abx
- Percutaneous cholecystostomy - drain infection
- BUT risk of recurrent disease remains as stones remain
Like nephrostomy but gallbladder
RUQ pain post cholecystectomy cause?
- Exclude retained CBD stone
- US abdomen needed
- MRCP may be needed if this is inconclusive
Complications of gallstones
- Mirizzi syndrome
- Gallbladder empyema
- Chronic cholecystitits
- Bouverets syndrome
- Gallstone ileus
What is Mirizzi syndrome?
- Stone located in Hartmanns pouch (outpouching of GB wall at the junction of cystic duct) OR in cystic duct
- Can then compress common hepatic duct
- = obstructive jaunduce even without stones being in CBD or common hepatic duct
- Need lap cholecystectomy
Chronic cholecystitits
- Recurrent/untreated cholecystitis
- Ongoing RUQ or epigastric pain
- Associated N+V
- Diagnose by CT imaging
- Elective cholecystectomy
Complications inc gallbladder carcinoma and biliary enteric fistula
