Cholelithiasis and Acute Calculous Cholecystitis

Question 1

Cholelithiasis is?

Answer 1

gall stones in the gallbladder than may be asymptomatic or symptomatic and is caused by stasis or imbalance in bile composition

Question 2

brown pigment gall stones are associated with

Answer 2

bacterial or parasitic biliary tree infection within the ducts only

Question 3

composition of brown pigment gallstones

Answer 3

the bacteria will deconjugate bilirubin and unconjugated bilirubin will precipitate with calcium forming calcium bilirubinate

Question 4

black pigment gallstones are associated with what conditions

Answer 4

hemolytic disorders like sickle cell, hereditary spherocytosis, G6PD deficiency.

Question 5

what is the composition of black pigment gallstones?

Answer 5

spontaneously deconjugated bilirubin cprecipitates with calcium and forms calcium bilirubinate

Question 6

what is the most common type of gall stone

Answer 6

yellow cholesterol stones

Question 7

what causes yellow stones

Answer 7

supersaturation of cholesterol that impedes the dissolving capacity of bile salts

Question 8

main causes of gall stones (pathology)

Answer 8

increased cholesterol, or increased bilirubin, or decreased bile acids, or bile stasis

Question 9

what are the risk factors for gallstones

Answer 9

high estrogenic states

female, forty, fertile , fat, fasting

Question 10

estrogen will increase the activity of what enzyme that plays a part in gallstone formation

Answer 10

HMG-CoA reductase

Question 11

how is fasting a risk factor for gallstone development

Answer 11

following a common surgery- bariatric surgery rapid weight loss can ensure and increased cholesterol metabolism and increased risk of cholesterol (yellow) gall stones

patient who are critically ill on TPN can also experience gall bladder stasis due to no CCK release and formation of cholesterol gallstones)

Question 12

How can inflammatory bowel disease and malabsorption conditions lead to gall stones

Answer 12

inflammatory disease: impair reabsorption of bile acids at the ileum–> cholesterol stones

malabsoprtion (ileal resection)–> cant solubolize cholesterol and bile acid malabsorption can also cause pigment stones

Question 13

how can fibrates cause gall stones

Answer 13

they decrease bile acid synthesis and can cause cholesterol call stones to form

other medications like somatostatin analogues, OCPs, ceftriaxone and hormone replacement therapy can cause gall stones as well

Question 14

indications for cholecystectomy in asymptomtic patients

Answer 14

chronic hemolytic disorders, increased risk of gall bladder cancer, gall stone bigger than 3 cm, adenomas, porcelin gall bladder

Question 16

what is biliary colic?

Answer 16

constant RUG or epigastric pain that is caused by the gallbladder contracting against an obstruction

pain may radiate to the R shoulder or R scapula

due to diaphragmatic irritation

Question 17

what is the hormone responsible for the contraction of the gall bladder

Answer 17

cholecystokinin

-pain in the cystic duct is obstructed upon contraction

Question 18

symptomatic cholelithiasis episodes last for how long

Answer 18

about 4-6 hours and then subside because the stone dislodges back into the gall bladder or passes through the cystic duct -> common bile duct -> duodenum

Question 19

symptomatic cholelithiasis physical exam findings

Answer 19

typically normal labs
RUQ tenderness -minimal

Question 20

diagnosis of cholelithiasis

Answer 20

ultrasound with finding of stones that are gravity dependent

hyperechoic foci with posterior acoustic shadowing
slude/liquid can also be seen

no CTs can be used because gallstones are isodense with bile

Question 21

supportive management in symptomatic cholelithiasis can include

Answer 21

pain control with NSAIDS, dietary modification (lower fat intake, less carbs) weight loss within limitis

Question 22

what is the definitive management of symptomatic cholelithiasis

Answer 22

elective laparoscopic cholecystectomy

Question 23

what drug may be used to determine if a patient will benefit from cholecystectomy?

Answer 23

urosodiol (ursodeoxycholic acid)

Question 24

what is acute cholecystitis?

Answer 24

inflammation, distention and infection of the gall bladder

Question 25

what is the most common cause of acute cholecystitis?

Answer 25

calculous (gallstone) blocking the cystic duct or the neck of the call bladder can also develop without the presence of a gall stone - acalculous

Question 26

Acute cholecystitis is typically inflammatory but can become infected with what organisms

Answer 26

E. coli, Enterococcous, Klebsiella, and Enterobacter transmitted through the portal system

Question 27

Acute cholecystitis pain presents how?

Answer 27

biliary colic that does not resolve with constant RUQ pain that may refer to the right shoulder or scapula

Question 28

common symptoms of acute cholecystitis

Answer 28

n/v, biliary RUQ pain, post prandial pain after a greasy meal, fever, tachycardia, hypotension (advanced cases), guarding, rebound tenderness, leukocytosis

Question 29

what sign is present with acute cholecystitis

Answer 29

Murphy sign cessation of inspiration while pressure is applied to the RUQ

Question 30

large elevations in transaminases, bilirubin or ALP suggests

Answer 30

choledocholithiasis (gallstone in the common bile duct)

Question 31

ultrasound in acute cholecystitis shows

Answer 31

gall bladder wall thickening, distended gall bladder, sludge, and pericholecystic fluid (edema sonographic Murphy's sign

Question 32

CT in acute cholecystitis can show

Answer 32

this imaging is less sensitive but can show fat stranding, and complications like a perforation or fistula -gallstones may not appear due to being isodense with bile

Question 33

what is a HIDA scan

Answer 33

a 99m technetium-labeled hepatic imilodiacetic acid scan that determines the function/filling of the gall bladder. If the scan is positive there will be no tracer in the gallbladder due to the cystic duct being blocker.

Question 34

supportive care options in acute cholecystitis

Answer 34

IV fluids, NPO, pain control (NSAIDS/Opiods), antibiotics until gallbladder is removed

Question 35

definitive management of acute cholecystitis

Answer 35

laparoscopic cholecystectomy within 72 hours

Question 36

what are the steps to a laparoscopic cholecystectomy

Answer 36

1. gain access to the abdomen and insufflate 2. identify and lift the gallbladder 3. dissect the gallbladder from base of the liver and clear fat to identify the cystic duct and artery from callots triangle 4. identify 2 tubular structures going to the gallbladder 5. ligate and transect the cystic artery and cystic duct and dissect the entire gallbladder off of the rest of the liver bed 6. remove and close the abdomen

Question 37

during a laparoscopic cholecystectomy there is an optional step called intraoperative cholangiogram which is?

Answer 37

this is when you inject contrast into the cystic duct and an x-ray or fluoroscopy is taken to see the biliary tree anatomy and see if there are any obstructions present

Question 38

what is an alternative to laparoscopic cholecystectomy in poor surgical candidates that decompressed the gallbladder

Answer 38

image guided percutaneous cholecystostomy tube placement

Question 39

what are some complications of acute cholecystitis

Answer 39

gangrenous/necrotic gallbladder (perforation and sepsis) perforation, abscess, peritonitis, sepsis emphysematous cholecystitis cholecystoenteric fistula gallstone ileus

Question 40

what is emphysematous cholecystitis

Answer 40

gas within the gallbladder wall from an infection with a gas forming bacteria like clostridium- gas will obscure the gallbladder on ultrasound *this requires emergency cholecystectomy

Question 41

complications with laparoscopic cholecystectomy

Answer 41

bile duct injury, retained stone, bile leak or biloma, bleeding, infection

Question 42

what is a biloma

Answer 42

fluid collection of bile

Question 43

complication of cholelithiasis

Answer 43

gallstone pancreatitis (most common cause of pancreatitis)

Question 44

what is a cholestoenteric fistula and gallstone ileus

Answer 44

a possible complication go acute cholecystitis where the gallbladder and duodenum form a fistula (track) between the two it can also cause narrowing of the ileum or ileocecal valve on the luminal side