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Case Nine - Acute cholecystitis Flashcards

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1
Q

what is acute cholecystitis caused by

A

a blockage in the cystic duct or neck of the gallbladder (95% of the cases are gallstones or sludge)

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2
Q

what can the obstruction cause

A

increase in mucus secretions from the gallbladder which causes gallbladder distension, and may affect the blood supply to the gallbladder

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3
Q

what is often the initial event in cholecystitis

A

often an obstruction to gallbladder emptying

in 95% of the cases, a gallstone is the cause. it is different to biliary colic because it is not a problem in the bile duct, but a problem in the gallbladder or in the cystic duct

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4
Q

what are the two effects of distension of the bile ducts

A

obstruction of blood flow to the gallbladder, as well as initiating an inflammatory response to the bile retained in the gallbladder

this can lead to mucosal damage, which in turn leads to the release of phospholipase,

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5
Q

what does phospholipase do

A

converts lecithin into lysolecithin which is a very potent toxin

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6
Q

what are the symptoms of acute cholecystitis and what are the y similar to

A

similar to biliary colic, and often differentiation is difficult

cholecystitis often results in a more prolonged pain with a fever and leukocytosis

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7
Q

what is Murphys sign

A

there will be RUQ pain

this is usually worse on inspiration. Murphy’s sign is where you would put your hand under the patient’s ribs and ask them to breathe in. As they do so, their gallbladder will be forced down against your hand, and it will cause them a lot of pain

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8
Q

when is Murphy’s sign only a positive result

A

only a positive result if the sign is negative in the LUQ

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9
Q

why does the pain radiate in acute cholecystitis and how does this differentiate

A

the pain is more likely to radiate to the shoulder tip in this than in other biliary conditions because the radiation is caused by irritation of the diaphragm and this is more likely in cholecystitis

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10
Q

what are the investigations carried out for acute cholecytsisis

A

FBC
serum amylase
serum bilirubin
USS

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11
Q

what would an FBC in acute cholecystitis show

A

raised ESR, CRP, WCC

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12
Q

what would a serum amylase show

A

increase as acute pancreatitis may be present as a compliation of gallstones

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13
Q

what would the USS detect

A

gallstones
gallbladder wall thickening
dilated common bile duct >6mm

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14
Q

what are the antibiotics given in acute cholecystitis

A

cefuroxime
metronidazole

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15
Q

what are the pain reliefs given in acute cholecysistis

A

usually diclofenac (NSAID) with pethidine (fast acting opioid) in more severe cases

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16
Q

what are the complications of acute cholecystitis

A

gangrene
bacterial infection and subsequent empyema

perforation

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17
Q

what is empyema

A

this is a collection of pus in the body cavity . it is different from an abcess, which is a colleciton of pus in a newly formed body cavity

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18
Q

what may be seen in patients with chronic cholecystisis

A

vague abdominal symptoms
sometimes associated with GI malignancy

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19
Q

what investigations are used to look for chronic cholecystitis

A

USS - evidence of gallstones and check common bile duct diameter

MRCP - may also be used to check for stones. In this procedure, MRI scanning is used to visualise the biliary tree. It is much less invasive than ERCP - which requires the insertion of dye into the biliary tree via OGD. ERCP has obvious therapeutic advantages that MRCP does not.

M,RCP is used to supplement USS

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20
Q

what is the treatment of chronic cholecystitis

A

ERCP - usually performed to remove any stones from the common bile duct and perform sphincterotomy before cholecystectomy

cholecystectomy - performed in troubling cases

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21
Q

what does the inflammatory response in acute cholecystitis cause

A

wall ischaemia and infection to ensue to cause localised peritonitis

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22
Q

what are the several modalities used to image a stone in the common bile duct

A

transabdominal ultrasound first line
MRCP
EUS

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23
Q

what is the gold standard for visualising stones in the CBD

A

endoscopic ultrasound (EUS)

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24
Q

why must any CBD stones causing obstructive jaundice be removed first prior to a laparoscopic cholecystectomy

A

a high biliary pressure from any obstruction can cause a bile leak from the cystic duct stump where the gallbladder is amputated during the cholecystectomy

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25
what does a thickened wall gallbladder indicate
either acute or chronic inflammation of the gallbladder
26
what kind of finding is pericholecystic fluid
an acute finding
27
what is the intial treatment in AandE of acute cholecystitis
Initial treatment would include: - Analgesia - Antiemetics - Antibiotics (according to hospital guidelines) - Fluid balance (intravenous fluids) - Venous thromboembolism prophylaxis - Nil by mouth, in anticipation for surgery
28
what definitive management would you offer
laparoscopic cholecystectomy surgery should be considered to remove the gallbladder on the same hospital admission (laparoscopic cholecystectomy)
29
what are the risks of laparoscopic cholecystectomy surgery
The general risks of surgery include bleeding, infection, pain, chest and urinary infections, deep vein thrombosis/pulmonary embolism and risks associated with general anaesthesia. Specifically for a laparoscopic cholecystectomy: - Damage to the common bile duct - Bile leak - Damage to surrounding structures (such as the duodenum or stomach) - Conversion from a laparoscopic procedure to an open procedure
30
what are the components of Charcot's triad for diagnosing acute cholangitis
right upper quadrant pain jaundice pyrexia
30
what does Reynolds pentad include
it has the three components of Charcot's - RUQ pain, jaundice and temp but it also includes mental status alterations and sepsis
31
what does an obstructive pattern of jaundice to the LFT's suggest
common bile duct obstruction
32
what is the definition of acute cholangitis
infection of the biliary tree caused by a downstream obstruction of the common bile duct
33
what are the causes of acute cholangitis
cholelithiasis (most common) benign biliary structure sclerosing cholangitis malignant strictures
34
what are the risk factors for acute cholangitis
age history of gallstones previous biliary surgery that may lead to a narrowing of the bile duct
35
what investigations should be performed to investigate a suspected diagnosis of acute cholangitis
an urgent US of the abdomen should be performed to investigate the cause of the biliary obstruction relieving the biliary obstruction will treat the cute cholangitis
36
what are the principles of treating a common bile duct obstruction
to either remove the cause or relieve the obstruction using a stent (in the case of a stricture) this can be achieved endoscopically by an ERCP
37
what is an ERCP
endoscopic retrograde cholangiopancreatohraphy it is an endoscopic procedure where a side viewing endoscope is used to identify and cannulate the ampulla of Vater which opens into the second part of the duodenum a radio-opaque dye is then injected retrograde and passes up Into the CBD and the pancreatic duct fluoroscopy are used to visualise the dye to detect any 'filling defects' that could indicate either a stone or a stricture
38
what is the advantage of an ERCP
that it can also be used to perform certain therapeutic procedures in the same procedure, such as extracting the stone using a wire basket, a sphincterterotomy of the sphincter of Oddi (to better allow the passage of bile) to to insert a stent across the obstruction to relieve the jaundice
39
what is ERCP NOT used for
a diagnostic procedure first line is USS and MRCP to diagnose the cause of the biliary obstruction before an ERCP os performed
40
what are the risks of ERCP
acute pancreatitis (5%) gastric/duodenal perforation bleeding risks associated with sedation
41
what is the initial treatment for acute cholangitis
Initial treatment would include: ● Analgesia ● Antiemetics ● Antibiotics (according to hospital guidelines) ● Fluid balance (intravenous fluids and urinary catheter) ● Venous thromboembolism prophylaxis ● Nil by mouth, in anticipation for an ERC
42
how would you treat acute pancreatitis after ERCP for acute cholangitis
analgesia antiemetics no antibiotics (still on these for cholangitis) fluid balance VTP
43
what is not a risk factor for developing gallstone disease
younger age
44
what condition is not associated with gallstone disease
peptic ulcer disease
45
what is Mirizzi's syndrome
this is compression of the CBD from a gallstone in Hartmann's pouch
46
A 35-year-old woman presents with intermittent right upper quadrant pain which lasts for a few hours each time she eats fatty foods. Bloods show a normal WCC and CRP, as well as normal LFTs and lipase. What is the most likely diagnosis?
biliary colic
47
A 78-year-old female presents with a 1-day history of confusion and ‘generally unwell’. She has a past medical history of hypertension and is known to have gallstones. Her observations are: BP 90/75, HR 120, RR 20 and a temperature of 38.9°C. On examination, she is visibly jaundiced, and she has guarding in her right upper quadrant. An urgent ultrasound scan shows a dilated common bile duct of 10mm with intrahepatic duct dilatation. After initial treatment of ABCDE, what is the definitive management of this patient?
ERCP this is the most appropriate treatment to clear the CBD of obstructing stones to treat the acute cholangitis
48
what is pancreatitis
condition involving inflammation of the pancreas. it can be acute or chronic
49
what accounts for the vast majority of pancreatitis episodes
gallstones and alcohol
50
what is the pneumonic used to remember the causes of pancreatitis
GET SMASHED
51
what does each letter in GET SMASHED stand for
G – Gallstones E – Ethanol (alcohol!) T – Trauma S – Steroids M – Mumps A – Autoimmune – e.g. SLE S – Scorpion bites (rare!) H – Hypercalcaemia, hypothermia, hyperlipiaemia E – ERCP D – Drugs – e.g. azathiaprin
52
what are the four steps of pathogenesis of pancreatitis
necrosis autolysis infection pseudocyst
53
explain the pathogenesis of pancreatitis
- the final common pathway has marked increase in intracellular calcium which then leads to activation of intracellular proteases - there is evidence that alcohol interferes with calcium homeostasis in pancreatic acinar cells - in severe inflammation, it becomes swollen and haemorrhaic - proteases digest the walls of the blood vessel which leads to blood extravasation - amylase is release into the blood - released lipase cause fat necrosis within the abdomen and subcutaneous tissue
54
what can the released lipase cause
discolouration of the skin - Grey Turner's sign
55
what can the released fatty acids bind to and what does this lead to
bind to Ca2+ and this leads to Hypocalcaemia
56
what can concomitant destruction of adjacent islets do
lead to hyperglycaemia and thus can cause type II diabetes
57
what is pulmonary failure in acute pancreatitis believed to be caused by
circulating activated digestion enzymes
58
what are these digestion enzymes
trypsin, phospholipase A2 etc
59
what does this circulating level of activated digestion enzymes lead to
a loss of surfactant, atelectasis and irritation eventually leading to ARDS, and pleural effusion
60
what else can also occur in severe acute pancreatitis
cardiac depression and breakdown of the BBB
61
what are the clinical features of acute pancreatitis
upper abdominal pain, normally beginning in the epigastrium accompanied by nausea and vomiting often radiates too the back
62
in severe cases of AP, what other symptoms can people have
tachycardia, hypotension and be oliguric
63
what would an abdominal examination show
widespread tenderness with guarding; also reduced/absent bowel sounds
64
what is Cullens sign
periumbilical bruising
65
what is Grey Turner's sign
flank bruising
66
when are Cullens and turners signs present
in severe necrotiising pancratiits
67
what is indicative in poor prognosis
left sided pleural effusion
68
what will blood tests show in pancreatitis
raised serum amylase, lipase , also with raised urinary amylase
69
is amylase prognostic
no, nor is the level related to the degree of tissue damage
70
what is the most specific blood test for pancreatitis
lipase levels, and may relate to the level of tissue damage, but levels do not rise up until 8 hours after the onset of symptoms
71
what imaging is used to exclude gaastroduodenal perforation
CXR is used which also causes raised serum amylase
72
what is the treatment for pancreatitis
replace lost fluids nasogastric suction to prevent abdominal distension and vomiting analgesia - pethidine and tramadol enteral nutrition
73
what are the three key cases of pancreatitis to remember
gallstones alcohol post-ERCP
74
how does alcohol cause pancreatitis
directly toxic to pancreatic cells, resulting in inflammation.
75
how much is amylase raised in pancreatitis
raised more than three times the upper limit of normal in acute pancreatitis in chronic pancreatitis it may not rise because the pancreas has reduced function
76
what is the Glasgow score
used to assess the severity of pancreatitis. it gives a numerical score based on how many of the key criteria are present: 0 or 1 – mild pancreatitis 2 – moderate pancreatitis 3 or more – severe pancreatitis
77
how can the criteria for the Glasgow score be remembered
using the PANCREAS pneumonic (1 point for each answer) P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10)
78
what may be required in chronic pancreatitis if there is loss of pancreatic enzymes
Creon
79
what are the two types of hiatus hernia
sliding hiatus hernia and rolling hiatus hernia
80
what is the most common type of hernia
sliding hiatus hernia. accounts for 95% of cases
81
what are they associated with
an increased incidence of GORD
82
what is a sliding hiatus hernia
when part of the stomach at the oesophageal gastric junction is pulled upwards through the diaphragm this reduces the angle between the oesophagus and the stomach, and thus removes one of the natural anatomic barriers to reflux.
83
how is the sliding hiatus hernia covered
only by peritoneum on its lateral and anterior sides the posterior is not covered due to the bare area on the back of the stomach
84
when does a rolling hiatus hernia occur
when part of the fundus of the stomach will extend through the diaphragm at a separate site to the oesophagus they can sometimes be huge, with almost the whole stomach becoming herniated, leading the gastro-oesophageal function lying right alongside the pylorus
85
what is the rolling hiatus hernia surrounded by
completely surrounded by a peritoneal sac
86
what are the three key complications of hernias
Incarceration Obstruction Strangulation
87
what does Courvoisier's law state
Courvoisier's law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
88
what are the features of carcinoid syndrome
abdominal pain diarrhoea flushing releases serotonin into systematic circulation when there is metastasis to the liver
89
what is the AST/ALT ratio in alcoholic hepatitis
the ratio is 2:1
90
what diagnosis has a positive pANCA test
primary sclerosing cholangitis
91
what is upper GI bleeding
bleeding from the oesophagus, stomach or duodenu
92
what are the causes of upper GI bleeding
peptic ulcers Mallory-Weiss tear Oesophogeal Marikes stomach cancers
93
what is a Mallory Weiss tear
a tear of the oesophagus mucosa
94
what is the presentation of upper GI bleeding
haematemesis (vomiting blood) coffee ground vomit melaena
95
what is the cause of coffee ground vomit
caused by vomiting digested blood with the appearance of coffee grounds
96
what does haemodynamic instability occur with
significant blood loss, causing low blood pressure, tachycardia, and other signs of shock
97
what are peptic ulcers associated with
history of epigastric pain and dyspepsia they may be taking NSAIDS
98
when do Mallory Weiss tears occur
after heavy retching or vomiting, which may be caused by binge drinking, gastroenteritis, or hyperemesis gravidum
99
when does hyperemesis gravidarum occur
during early pregnancy
100
what are oesophageal varcices associated with
liver cirrhosis and portal hypertension the patient will have signs of these conditions, such as ascites, jaundice and caput medusae
101
what is stomach cancer associated with
history of weight loss, epigastric pain, treatment resistant dyspepsia, low haemoglobin (anaemia) and a raised platelet count
102
what is the bleeding score used in the initial presentation of a suspected upper GI bleed
the Glasgow-Blatchford score
103
what does the Glasgow-Blatchford score do
estimates the risk of patient having an upper GI bleed
104
what score on the Glasgow Blatchford scale indicates high risk bleed
a score above 0 indicates a high risk for an Upper GI bleed
105
what factors does the Glasgow-Blatchford score take into account
Haemoglobin (falls in upper GI bleeding) Urea (rises in upper GI bleeding) Systolic blood pressure Heart rate Presence of melaena (black, tarry stools) Syncope (loss of consciousness) Liver disease Heart failure
106
what is the association between an upper GI bleed and increased blood urea
acid and digestive enzymes break down blood in the upper GI tract. one of the breakdown products is urea, which is then absorbed into the intestines, causing a rise in blood urea
107
what is the management of an upper GI bleed
the ABATED pneumonic
108
what does the ABATED pneumonic stand for
A – ABCDE approach to immediate resuscitation B – Bloods A – Access (ideally 2 x large bore cannula) T – Transfusions are required E – Endoscopy (within 24 hours) D – Drugs (stop anticoagulants and NSAIDs)
109
what do you send bloods for in suspected GI bleed
Haemoglobin (FBC) Urea (U&Es) Coagulation (INR and FBC for platelets) Liver disease (LFTs) Crossmatch 2 units of blood
110
what is group and save
when the lab checks the patient's blood group and saves a blood sample to match blood if needed. crossmatch is where the lab allocated units of blood, tests that it is compatible and keeps it ready in the fridge
111
when are blood, platelets and clotting factors given
to patients with a massive bleed
112
what is given in active bleeding
platelets are given in active bleeding plus thrombocytopenia (platelet count less than 50)
113
what is given to patients taking warfarin that are actively bleeding
prothrombin complex concentrate
114
what are the additional steps taken if oesophageal varies are suspected
terlipresisn broad spectrum antibiotics
115
what is required to diagnose and treat the source of the bleeding
OGD (endoscopy)
116
what do the NICE guidelines recommended against using until after Endoscopy in patients with non-varicial upper GI bleeding
recommend against using a proton pump inhibitor
117

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