Case 9: Right Upper Quadrant Pain Flashcards
(50 cards)
the biliary system
right and left hepatic duct join to form the common hepatic duct
common hepatic duct joins the cystic duct to form the common bile duct
process of haem to bilirubin
happens inside marcrophage
haem converted to biliverdin via haem oxygenase
biliverdin converted to bilirubin via biliverdin reductase
what converts bilirubin to urobilinogen (stercobilinogen)
happens in intestine
glucuronic acid is removed via bacteria
urobilinogen can then be converted to stercobilin too
common risk factors for gall stones
common risk factors for gall stones
diet high in triglycerides, refined carbohydrates and low fibre diets
diabetes
prolonged fasting or rapid weight loss
obesity
hormone replacement therapy
female
increasing age
what are the most common type of gall stones in the UK
cholesterol stones
cholesterol stones
what are the borders of calots triangle
inferior border of liver
common hepatic duct
cystic duct
what is the importance of calots triangle
contains cystic artery (blood supply to gall bladder)
this must be identified during cholecystectomy
typical presentation of biliary colic
RUQ pain
cramping pain (comes in waves)
comes on suddenly and comes and goes over a period of weeks
can radiate to back and right shoulder blade
pain comes on shortly after eating
can get nausea during pain
pain for few hours then goes
can come on after fried foods
10/10 pain
what is biliary colic
obstruction usually by stones in the cystic duct of the biliary tree
therefore when one eats fatty foods and the gallbladder contracts to release bile, this is when the pain comes on
if your top differential was gallstones which diagnostic test would you do
trans abdominal ultrasound
triad for acute cholangitis
pyrexia
jaundice
RUQ pain
other name for gallstones
cholelithiasis
the formation of gallstones is precipitated via what
imbalance of bile salts and cholesterol
what stimulates the gall bladder to release bile
cholecystiokinin (CCK) (released via I cells inn duodenum) stimulates the gall bladder
is there an infection in biliary colic
no therefore WCC and CRP are normal
treatment of biliary colic
conservative management- fat-free diet and simple analgesia (paracetamol)
surgical management- laparoscopic cholecystectomy
what can gallstones lead to
acute cholecystitis- 1-3% of patients with symptomatic gallstones will develop acute infection of the gallbladder
acute cholangitis- about 50% of patients with acute cholangitis have gallstone aetiology
acute pancreatitis- up to 70% of acute pancreatitis cases are due to gallstone disease
when to advise someone with gall stones to attend A&E
uncontrolled pain
fever
persistent vomiting
example presentation for acute cholecystitis
RUQ pain
constant pain which started after eating
can radiate to back and right shoulder
may feel nauseous
paracetamol not making it better
9/10 pain
what is acute cholecystitis
inflammation of the gallbladder usually when gallstones block the cystic duct (gallstones remain in the gallbladder and do not obstruct the common bile duct)
examination findings for cholecystitis
abdominal pain
guarding
rebound tenderness
what can be seen in bloods with acute cholecystitis
raised WCC
raised CRP
as the gall stones do not obstruct the common bile duct there is not obstructive derangement of the LFTs
example of how to refer someone to a ward (general surgery team in case of acute cholecystitis)
SBAR
introduce yourself and say you want to refer someone, check they are in a place where they can discuss confidentially
situation- their name and presenting complaint
background- history of presenting complaint and examination and investigation findings
assessment- diagnosis and why you want to refer them (which surgery/procedure)
recommendation- would you be able to come and see this patient please with a view for hospital admission?
what does the inflammatory response in acute cholecystitis cause
wall ischaemia and infection to ensue to cause localised peritonitis (this causes the shift from the colicky pain of biliary colic to a more constant pain from peritonitis)
