Cholecystitis Flashcards Preview

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Flashcards in Cholecystitis Deck (19):
1

Types of gall stones

1. Pigmented: hemolysis

2. Cholesterol: large->+age, obesity

3. Mixed: calcium salt + cholesterol 90% asymptomatic

2

Risk factors cholecystitis

1. Calculous

Cholesterol gall stones: Female, fat, forty, fertile, pregnant, OCP, rapid weight loss

Pigmented gall stones: hemolytic disease, salmonella, infection

2. Acalculous (stasis)

Severe illness, sepsis

Cardiac

TPN, prolonged fasting

Physical inactivity

Low fibre

Trauma

Severe burns

Ceftriaxone

Infections

3. Other

Sickle cell

Diabetes

AIDS->CMV, cryptococcus

3

Clinical features

RUQ pain

Previous biliary pain

+ve murphy's

Abdominal mass

Right shoulder pain,

Anorexia, nausea, fever, vomiting

4

Investigations

FBC->+WBC

CRP->elevated

LFTs->elevated ALP, GGT, bilirubin

Amylase->pancreatitis

RUQ USS->pericholecystic fluid, distended gall bladder, thickened wall, +ve murphy's sign

5

Criteria

1. Local signs of inflammation

2. Systemic signs of inflammation->fever, CRP, WCC

3. Imaging findings

6

Management

1. ABC, assess severity

2. NBM

3. IVF, investigations->FBC, UEC, CRP, USS, AXR/ECXR (depending on presentation)

4. Antibiotics: Gentamicin + amoxycillin

5. Analgesia (diclofenac) + antiemetic

6. Monitoring->BP, pulse/RR, urinary output

7. Surgical consult

8. Admit, book and consent . Complete pre-op workup

8. Laparoscopic cholecytectomy within 48 hours

7

USS findings

1. Bright echoic with acoustic shadowing

2. Thickened wall

3. Halo 4. May show stones, dilation of the duct

8

When in ERCP indicated

1. Not in uncomplicated gall stone disease

2. Recurrent biliary pain/pancreatitis when gall stones suspected of being underlying cause but not identified on USS

9

Possible clinical situations with gall stones

1. Incidental gall stones on USS

2. Incidental at laparotomy

3. Biliary colic 4. Cholecystitis

5. Obstructive jaundice

6. Cholangitis

7. Gallstone ileus

8. Pancreatitis

9. Mucocele/empyema

10. Mirizzi's

11. Perforation

10

Management of incidental gall stone on USS, cumulative incidence of requiring a lap chole

1. Unless evidence of biliary pain- do nothing

2. Cumulative incidence of requiring a lap chole is 1% per year

11

Management when incidental at laparotomy

1. +risk of becoming symptomatic, 75% at 12 months

2. If adequate exposure, tolerating anaesthesia, can add cholecystectomy and cholangiography

12

Management of biliary colic

1. Once pain, increased risk of ongoing

2. At 5 years, all will have recurrence and 20% will develop a complication

3. Unless operative risk ++, or low life expectancy operation

4. Analgesia, hydration, NBM, elective cholecystectomy

13

Pre-operative treatment

1. Fasting

2. Prophylactic Antibiotics->cefazolin

3. DVT prophylaxis

14

Post operative when laparoscopic

1. 2 weeks until return of activity

2. Less pain and ileus

3. Ambulant day of surgery

4. Narcotics 1 day, simple oral analgesia for 10 days

15

Post-operative when open

1. ++Pain

2. DVT prophylaxs

3. 5 day hospital stay

4. PCA

5. NBM for 24-48 hours->+ileus

6. IVF two days

7. Four weeks until normal return of activity

16

Specific complications

1. Bile duct injury->suspect if ongoing pain and fever, LFTs immediately->if +cholangiogram required

2. Persistent/recurrent biliary pain->retained stone, SOO dysfunction, wound neuragial, nerve injury, original pain not due to gall stone

17

Acalculous

Gallbladder inflammation caused by biliary stasis (in 5% of patients with acute cholecystitis) leading to gallbladder distension, venous congestion, and decreased perfusion; it nearly always occurs in patients hospitalized with a critical illness.

18

Cholangitis

1. Infection within the bile ducts, most commonly caused by complete or partial obstruction of the bile ducts by gallstones or strictures.

2. The classic Charcot triad (RUQ pain, jaundice, and fever) is seen in only 70% of patients.

3. This condition may lead to life-threatening sepsis and multiple-organ failure.

4. Treatment consists of antibiotic therapy and supportive care; in cases of severe cholangitis, endoscopic decompression of the bile duct by endoscopic retrograde cholangiopancreatography (ERCP) or surgery is indicated.

19

Biliary dyskinesia investigation

1. Obtain a CCK-stimulated HIDA (hepatobiliary iminodiacetic acid) scan When typical features of biliary colic, with negative USS of stones