When do you recommend surgery for gall stones?
A second episodes of symptoms within 3 months of the first episode
Three episodes in a year
What is a cholecystostomy?
Surgical placement of a drain to remove pus in a gallbladder empyema and sepsis in order to stabilise a patient prior to definitive cholecystectomy
What is the normal diameter of the CBD?
2mm + 1mm/decade of life
What is the classic symptomatology of biliary colic?
RUQ pain (+/- to back)
Typically following a fatty meal
Constant pain that eventually recedes
How do you differentiate cholecystitis from biliary colic?
The pain is constant and will not go away at any point, if it does go away then it's biliary colic
What is Charcot's triad?
Why do you use Abx in cholecystitis? Which ones do you use?
What is the most common type of gall stone? How do they form?
Supersaturation of cholesterol in the gall bladder in a area of stasis and precipitation into stones
When do you operate for cholecystitis?
As soon as possible
What are some US findings for cholecystitis?
Stones, perhaps in Hartman's pouch
Rule out empyema, abscess
How might the passing of a troublesome gall stone be reflected in laboratory findings?
Decrease in bilirubin and liver enzymes
How is acute cholecystitis managed?
It is considered a surgical emergency but can be managed conservatively with antibiotics and fluids
For which disease is Murphy's sign most sensitive?
What are some symptoms of cholecystitis?
Constant (>12 hours) RUQ pain
How does the pain of biliary colic and cholecystitis differ?
Biliary colic pain is less well localised and not accompanied by tenderness and guarding
Cholecystitis pain is well localised to the RUQ and often accompanied by tenderness and guarding
Why doesn't Xray play a role in choleliathiasis?
Only 10-30% of cholesterol and pigment stones are radio-opaque
How do you managed cholecystitis non-surgically?
Cholecystostomy (radiological drainage of GB)
Which cholelithiasis related condition presents with painless jaundice and an obstructive picture on liver enzymes?
What is the name of the process where fluid builds up in the gallbladder secondary to an obstruction?
What is gallstone ileus?
When a sufficiently large gall stone erodes through the wall of the gall bladder and travels into the duodenum down and blocks the ileum
What is chronic cholecystitis caused by?
Fibrosis and loss of the function of the gall bladder due to long term stones
What are some symptoms of gall stones?
What is unique about cholangitis?
What percentage of people have gall stones in their lifetime? What percentage of those get symptoms?
How is choleliathiasis managed?
Medically - bile salt therapy
- Dissolution - Ursodeoxycholic acid
Surgery - Cholecystectomy - for patients with symptomatic disease or asymptomatic if they're at high risk of not tolerating complications
Endoscopic retrograde sphincterotomy
How does cholangitis typically present on hx?
RUQ pain - can radiate to the tip of the shoulder
What type of inflammation occurs in cholecystitis?
What are some DDx of cholelithiasis complications?
Malignancy of surrounding viscera
What are some factors that predispose one to developing cholelithiasis?
Female, fat, forties, and fertile
Hyperlipidaemia and hypercholesterolaemia
Cholestatis - spinal cord injury
How does pancreatitis pain differ from cholelithiasis related pain?
It is more severe
Epigastric, sometime radiating to the back
Sharp and continuous
What are some definitive treatment methods for cholangitis?
GB exploration (if performing cholecystectomy)
Why is a CTIVC better than an MRCP?
Because it gives a indication of excretory function
What is the CT used for gallbladder? When is it contraindicated?
CT IVC (cholangiography)
When the bilirubin is >30
What are some types of gall stones?
What is Reynold's pentad?
Charcot's triad (fever, jaundice, RUQ pain)
When are endoscopic retrograde sphincterotomy's indicated?
When a cholecystectomy wouldn't be tolerated
To remove gall stones left after a previous cholecystectomy
What is the temporal cut off between biliary colic and cholecystitis?
What is the course of action if a gallbladder polyp is found?
If 5-10mm monitor
If >10mm intervene
What is gallstone ileus?
When a gallstone erodes through the bladder into the duodenum and causes obstruction, usually at the ileocaecal junction
What are the Abx of choice for biliary infections/cholangitis?
Ceftriaxone + metronidazole
What is Mirizzi's syndrome?
CBD obstruction due to a stone in Hartmann's pouch