Gallbladder disease

Question 1

What does bile contain

Answer 1

Water
Cholesterol
Bile pigments
Phospholipids

Question 2

How is bile secreted by gallbladder

Answer 2

Bile produced in liver
Then stored and concentrated in gallbladder

Lipid rich food in duodenum stimulates CCK release which causes Gallbladder contraction. Bile passes from the hallbladder into the duodenum

Question 3

What results in gallstone formation

Answer 3

Supersaturation of bile

Question 4

factors which contribute to gallstone formation

Answer 4

Cholesterol supersaturation.

• Caused by increased plasma oestrogen [female, forty, fat, fair, fertile (one or more children), + fam history)
• Caused by depletion of the bile acid pool –> terminal ileum resection or disease

Stasis of bile
-Lack of stimulus to GB emptying (fasting, TPN)

Increased Hb breakdown
-Haemolytic disorders (spherocytosis, sickle cell or malaria)

Question 5

What are the 3 gallstone compositions

Answer 5

Cholesterol (often solitary, smooth, large)

Mixed (predominantly cholesterol, multiple, generations range of colours and shapes)

Pigment (bile pigments, multiple, small, irregular and fragile)

Question 6

What is cholelithiasis

Answer 6

Stones in the gallbladder

Question 7

What is choledocholithiasis

Answer 7

Stones in the bile duct

Question 8

What is cholestasis

Answer 8

reduction or stoppage of bile flow

Question 9

What is biliary colic

Answer 9

when cystic duct becomes impacted by gallstone

Question 10

Pain of biliary colic

Answer 10

Sudden, sharp, stabbing, RUQ- epigastric pain. Typically radiates to right shoulder and lasts <6h

Question 11

Associations of pain of biliary colic

Answer 11

Eating (esp fatty foods)

Associated N&V

Question 12

Examination findings of biliary colic

Answer 12

Apyrexial. typically unremarkable

Question 13

Investigations nad management of biliary colic

Answer 13

Stones on USS

-Ultrasound, outpatient cholecystectomy

Question 14

IS jaundice present in biliary colic

Answer 14

No as bile can still drain via common bile duct

Question 15

What is cholecystitis

Answer 15

Stone impacted in neck go gallbladder or cystic duct results in super concentrate, irritant. Bile can get infected by ascending gut bacteria (klebsiella, e.coli)

Question 16

What bacteria can cause infections in cholecystitis

Answer 16

Klebsiella

E. coli

Question 17

Pain and associations in cholecystitis

Answer 17

Pain- constant RUQ- epigastric pain which persists. Main radiate to right shoulder

Associations- may babe N&V. Likely to have fever and or lethargy

Question 18

Examination findings in cholecystitis

Answer 18

Tender RUQ with possible guarding.

Murphy’s sign - Whilst applying pressure in RUQ ask patient to inspire deeply. Positive when there is a halt in inspiration due to pain. Similar manoeuvre in LUQ should not elicit discomfort

Question 19

Investigation findings in cholecystitis

Answer 19

Raised inflammation markers

Mildly raised AST/ALT/ALP

May have slightly raised bilirubin

USS shows enlarged gall bladder with stones and thickened walls

Question 20

Management of cholecystitis

Answer 20

Analgesia
Nil by mouth
IV fluids
Cholecystectomy within one week
Antiemetics if required 
Antibiotics (cef + met)

Question 21

Are patients jaundiced in cholecystitis

Answer 21

No

Question 22

What is cholangitis

Answer 22

Biliary outflow obstruction and ascending infection

Question 23

What pain and associations are there in cholangitis

Answer 23

RUQ, persistent, colicy in nature?

Jaundiced, typically unwell and pyrexial with rigors
-May also have pruritus, pale stool and dark urine. Often causes sepsis

Question 24

Examination findings in cholangitis

Answer 24

Tender RUQ with possible guarding. Pyrexial. Jaundiced.

Question 25

Investigation finding in cholangitis

Answer 25

raised WCC, blood cultures Raised bilirubin Raised ALP/GGT> AST/ALT USS shows dilated bile ducts and/or gall bladder stones and/or ductal stones

Question 26

Management of cholangitis

Answer 26

Analgesia, Nil by mouth IV antibiotics ERCP

Question 27

What blood tests to do if suspect gallbladder disease

Answer 27

FBC, U&E, LFT, CRRP, amylase VBG+ blood cultures --> cholangitis

Question 28

What imaging options to use if ultrasound is inconclusive

Answer 28

CT scan MRCP - detailed visualisation of biliary tree ERCP- Contrast passed into biliary tree so you. can see. Whilst there, can unblock common bile duct. Gold standard for cholangitis

Question 29

What is a T tube and why is it used

Answer 29

Used if ERCP fails in cholangitis - Prevents common bile duct blockage due to swelling - Prevents bile leakage into Abdo cavity - Not reco. ended for routine use

Question 30

Wn a patient with painless jaundice and enlarged gallbladder what Is the likely cause

Answer 30

Obstructing malignancy until proven otherwise

Question 31

What is gallstone ileus

Answer 31

Inflammation of the gallbladder can cause a fistula between the gallbladder wall and the duodenum allowing gallstones to pass into the small bowel directly. if a stone impacts a terminal ileum this results in small bowel obstruction.