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Flashcards in gallbladder Deck (67):
1

Choledocholithiasis is

formation and migration of stones inside the biliary tree or common bile
duct

2

pigment stones

– contain bilirubin and
calcium - radiopaque

3

Risk factors for pigment gallstones:

1) hemolytic conditions (sickle cell anemia (beta chain issue),
hereditary spherocytosis, thalassemia (absence of 1 globulin))
2) liver cirrhosis
3) intraductal stasis (choledochole cyst, postsurgical billiary stricture)

4

Risk factors for mixed gallstones:

1) Crohn’s disease
2) partial removal of ilium
3) decreased gallbladder motility:
- severe trauma (e.g. car accident)
- severe burns
- paralysis

5

gallstones are asymptomatic in what percent of patients

70-80%

6

gall stone attack

- sudden acute pain in the right upper quadrant,
lasts 30 minutes to several hours, until the
gallbladder relaxes
- pain radiates to back, between blades, right
shoulder, behind sternum
- change of posture, defecation do not relieve
pain

7

_____ is positive in Cholelithiasis
only when it is complicated with Cholecystitis

Murphy’s sign

8

Murphy’s sign is negative with

the stone
in the bile duct (Choledocholithiasis)

9

Cholelithiasis signs and symptoms

- tachycardia
- nausea, vomiting (vomiting does not relieve pain)
- increased production of gas
- fat intolerance

10

Signs and Symptoms in
Choledocholithiasis:

- the Charcot triad (indicates the ascending cholangitis)
= severe right upper quadrant pain
= jaundice
= fever

- acute constant pain in the upper part of the
abdomen
- obstructive jaundice
- Murphy’s sign is negative

11

Cholelithiasis diagnosis

-Blood tests are informative in the cases of exacerbation:
- increased WBC (during migration only)
- increased common bilirubin content (left shift)
- increased alkaline phosphatase (enzyme present in liver and bile, synthesized by pregnant women)
-High ALP
-ultrasound
-CT
-MRI
-ERCP (endoscopic retrograde cholangiopancreatography)
-xray (porcelain gallbladder)

12

ALP

-Alkaline phosphatase (ALP) is an enzyme presenting in all tissues of the body, but is particularly concentrated in: liver, bile duct, kidneys, bones, placenta

13

-High ALP can show:

- liver disease
- bile duct obstruction
- presence of Paget’s disease with osteoblastic
activity
- presence of pregnancy
- presence of Celiac disease

14

gold standard for exam and diagnosis of gallbladder stones

ultrasound

15

“porcelain
gallbladder”

characterized by calcification of gallbladder wall, developing usually in cholelithiasis complicated by chronic cholecystitis

16

Radiologic exam can be used for differential diagnosis
between gallbladder and kidney stones.
On lateral lumbar X-ray film:

- the gallstones locate in front of lumbar spine - the kidney stones overlap L2 or locate posterior to it

17

acute cholecystitis

when the cystic duct is obstructed

18

chronic cholecystitis,

when long-term
presence of gallstones (“silent” stones)
leads to fibrosis of the gallbladder wall,
with further its calcification (“porcelain
gallbladder”)

19

complications of cholelithiasis

-acute cholecystitis
-chronic cholecystitis
-gallbladder gangrene
-perforation of rupture
-cholangitis
-acute pancreatitis

20

perforation or rupture of
the gallbladder

with
development of bile peritonitis
and high level of mortality

21

cholangitis

when the common bile duct
is obstructed before joining
the pancreatic duct

22

acute pancreatitis

when the hepatopancreatic duct or pancreatic duct is obstructed

23

Cholecystitis

is defined as inflammation
of the gallbladder wall.

24

the two forms of cholecystitis?

-calculous
-acalcolous

25

calculous

when stones in the
gallbladder are formed – 90%

26

acalcolous

-without formation of stones
-10%
-most severe

27

Risk factors for calculous cholecystitis:

- female sex
- obesity
- rapid weight loss
- multiple pregnancies
- increasing age >35-40
- ethnic groups (Hispanic, Scandinavian)
- drugs (especially hormonal therapy
in women)

28

Etiology of acalculous cholecystitis

- critical illness (HIV, diabetes mellitus,
myocardial infarction)
- major surgery or severe trauma/burns
- sepsis
- long-term total parenteral nutrition
- prolonged fasting
- Salmonella infection

29

Pathogenesis of acute cholecystitis

etiological agents

decrease the gallbladder motility

delay of bile evacuation

increase of pressure inside gallbladder, increase of bile concentration, activation of opportunistic bacteria (e.g. E.coli)

inflammation of gallbladder wall

30

Pathogenesis of acute cholecystitis

inflammation of gallbladder wall
↓ ↑
edema of gallbladder wall

compromising of blood flow and lymphatic drainage in
gallbladder wall and surrounding tissue

ischemia and necrosis of gallbladder wall
and surrounding tissue

31

Pathogenesis of chronic cholecystitis:

Chronic cholecystitis occurs after repetitive mild
exacerbations of acute cholecystitis, and is
characterized by mucosal atrophy and fibrosis of
gallbladder wall

32

Signs and symptoms of acute cholecystitis

- acute pain in right upper abdomen that is severe
and constant, may last for days (!)
- this pain is increased with breathing
- pain radiates to right shoulder, or right scapula,
or right mid back (T8 –T9 levels)
- changing position and passing gas do not
relieve the pain
- large amount of meal or fat meal can trigger the
pain
- pain occurs several hours after eating and
awakens the patient during the night
- fever and chills
- nausea and vomiting
- vomiting does not relieve the pain (unlike to
peptic ulcer)

33

Signs and symptoms of chronic cholecystitis:

- the first symptoms are bitter taste and taste of
metal in the mouth in the mornings
- abdominal discomfort after meals
- complaints of gas accumulation
- nausea
- chronic diarrhea
- presence of skin xanthomas

34

skin xanthomas

Xanthomas represent focal accumulation of cholesterol, result from cholestasis or/and hyperlipidemia

35

diagnosis of cholecystitis

-ortner's sign
-georgievskiy-myussi's sign
-Murphy's sign
-Boas'sign
-blood test
- ultrasound sonography
- MRI
- CT-scan
-HBS- hepatobiliary scintigraphy

36

Differential diagnosis – for acute
cholecystitis:

- acute peptic ulcer
- perforated peptic ulcer
- acute pancreatitis
- ureteral colic

37

Differential diagnosis – for chronic
cholecystitis:

- peptic ulcer
- hiatal hernia
- colitis
- chronic pancreatitis

38

cholecystitis Complications:

- perforation or rupture of gallbladder
- ascending cholangitis
- local abscess
- peritonitis

39

Management of acute cholecystitis:

cholecystectomy

40

Management of chronic cholecystitis:

-diet modification
-antibiotics
-restriction of physical activity

41

Pancreatitis

when certain enzymes that normally do not
become active until they reach the small
intestine, become active in the pancreas
“digesting” this gland itself
-The enzyme Trypsin plays the most important role
in this process

42

Types of pancreatitis:

1) acute – is reversible disease, if does not turn
into chronic pancreatitis
2) chronic – is irreversible disease,
characterized by atrophy, fibrosis, and
calcification of pancreatic parenchyma

43

Etiology for acute pancreatitis

- alcohol use (even once)
- gallstones
- trauma of the abdomen
- viral infections (e.g. Mumps)
- pseudocysts
- medications (corticosteroids, estrogen, statins)

44

Etiology for chronic pancreatitis

- alcoholism
- cystic fibrosis
- pseudocysts
- idiopathic

45

Signs and Symptoms for acute pancreatitis

- sudden acute, severe pain in upper abdomen,
lasts from short time to days, and resolves
itself
- pain worsens after food eating
- pain may reach to across the back, level
T8–L1 – so called “band-like” pain
- pain could radiate to other areas:
= umbilical
= both flanks
= left shoulder
- pain worse when lying flat on the back
- pain decreases with sitting and flexion
forward (unlike to pain in cholelithiasis and acute cholecystitis)
- this pain is always accompanied by high blood pressure and tachycardia
- positive Cullen’s sign
- positive Grey-Turner’s sign
- nausea
- vomiting
- fever

46

where is the band-like pain located from acute pancreatitis

T8-L1 across the back
-pain could radiate to :
-umbilical
-both flanks
-left shoulder

47

when is pain worse in acute pancreatitis?

-when laying flat on the back
-after eating food

48

when is pain decreased in acute pancreatitis?

-with sitting and flexion forward

49

Cullen’s sign

– is superficial edema
and bruising in the subcutaneous fatty tissue
around the umbilicus

50

Grey-Turner’s sign

ecchymosis of flanks
-bruising of the flank, which may be indicative of
pancreatic necrosis with retroperitoneal or
intraabdominal bleeding

51

what sign can predict acute pancreatitis

both Cullen’s and Grey-Turner’s signs can
predict acute pancreatitis

52

Signs and Symptoms for chronic pancreatitis

- acute pain is not resolved itself
- pain increases after eating and drinking
- change of position does not relieve the pain
- band-like pain
- nausea
- severe vomiting
- fatty stool
- signs of diabetes mellitus II only: thirst, polyuria
- weight loss

53

Diagnosis:

- blood amylase and lipase are 4-6 times higher
than normal variations
Lipase is better indicator!
- urine amylase is significantly increased
- blood glucose level increased
- ultrasound
- CT-scan
- MRI

54

Complications for acute pancreatitis

- pancreatic
abscess
- pancreonecrosis
- acute gastritis and duodenitis because they
are adjacent organs
- internal bleeding with development of
hypovolemic shock
- lung problems (enzymes may affect the lung
tissue causing its inflammation)

55

Complications for chronic pancreatitis

- diabetes mellitus
- pancreatic cancer
- calcification of pancreas
- multiple cysts

56

Pancreatic Cancer

-is a malignant neoplasm
originating from transformed cells of the pancreas
-The most common type is Adenocarcinoma (95%), arising from the exocrine component, from the cells that line the ducts of the pancreas

57

Predisposing Factors for pancreatic cancer

- chronic pancreatitis
- smoking
- family history
- age over 60 years old - diet with high amount of red meat, soft drinks
- obesity
- partial gastrectomy as treatment of obesity
- Helicobacter pylori infection

58

pancreatic cancer Signs and Symptoms

-early is asymptomatic aka the "silent" disease
- unexplained weight loss
- anorexia
- nausea, vomiting
- steatorrhea (pooping fat)
-clinical depression
- painless jaundice, may be associated with
itching
- jaundice develops when the cancer locates
in the head of pancreas
-pain in upper abdomen, radiates to back if tumor is in body or tail
-trousseau sign
-pulmonary embolism

59

what is the most common location for pancreatic cancer?

head -75%
body -15%
tail -10%

60

Trousseau sign

unexplained thrombophlebitis of superficial veins anywhere in the body,
portal vein or deep veins of the extremities

61

pulmonary embolism is a symptom of pancreatic cancer

because the pancreatic cancer produces the blood clotting chemicals

62

Pancreatic cancer diagnosis

-blood CA-19-9 – this is a tumor marker that
is frequently elevated in pancreatic or liver cancer
- CT-scan
- endoscopic ultrasound (EUS)
- endoscopic ultrasound with endoscopic needle
biopsy

63

pancreatic cancer Metastases steps

#1 – to regional lymphatic nodes
#2 – liver-portal vein
#3 – lungs and pleura

64

Endocrine Pancreatic Tumors

- Insulinoma
- Zollinger-Ellison syndrome

65

Insulinoma

-located in tail
-endocrine pancreatic tumor
- beta-cell tumor, generally
benign, is characterized by overproduction of
Insulin, which can result in hypoglycemia

66

Zollinger-Ellison syndrome Gastrinoma

-arises in the duodenum, pancreas and
peripancreatic soft tissue
- It is characterized by overproduction of Gastrin
which stimulates extreme hydrochloric acid
secretion
- it causes multiple peptic ulceration not only in
the stomach and duodenum, but also in
jejunum
- it can metastasize to the liver leading to
significantly short life

67

Zollinger- Ellison syndrome Diagnosis:

- blood testing to detect increased gastrin levels
- upper gastrointestinal (GI) endoscopy
- imaging tests to look for gastrinoma
- measurement of stomach acid
(gastric pH less than 2.0; large gastric volume >140 mL)
is highly suggestive of ZES