Gallstone Disease

Question 2

What is the incidence of gallstones in >50s?

Answer 2

10%

Question 3

What are some RFs for gallstone disease?

Answer 3

Question 4

What are the major components of bile? Where is bile stored? Where is it secreted and what controls its secretion?

Answer 4

Question 5

What causes the release of CCK?

Answer 5

Question 6

What are the risks for developing a cholesterol gallstone vs a bile salt stone?

Answer 6

Question 7

How is gallstone formed? What are the types of gallstones? What is the most common?

Answer 7

Question 8

What is the typical presentation of gallstones?

Answer 8

asymptomatic

Question 9

What causes biliary colic. Why is it a colicky type pain. (why is the pain not constant)

Answer 9

Question 10

A patient with chronic cholecystitis presents with intermittent N+V, bloating, constipation and generalised abdominal pain. What is the most likely cause? How does it explain this presentation

Answer 10

gallstone ileus - usually gets stuck at ileocaecal valve, but it can also erode through the gallbladder causing a cholecystoduodenalfistula.

Question 11

A patient has a previous history of biliary colic and has now presented with CONSTANT SEVERE epigastric pain. What is a possible reason for her new symptoms?

Answer 11

Question 12

A patient has a recent history of biliary colic and acute cholecystitis. She now presents with fever, tachycardia, tachypnea and hypotension. There is no dilation of the biliary tree on US. Why did this occur (give 2 possibilities)? How will it be managed?

Answer 12

Or can be perforated leading to peritonitis. If exam was performed and no rebound tenderness + present bowel sounds, it’ll be empyema only

Question 13

A patient has a recent history of biliary colic and acute cholecystitis. She now presents with fever, tachycardia, tachypnea and hypotension. Given that the most likely cause of her presentation is an empyema of the gallbladder, what are the possible sequelae if left untreated? Include the management of the sequelae.

Answer 13

Question 14

A patient with a recent history of biliary colic presents to the clinic with a large tense RUQ mass. Why do you think this occured?

Answer 14

Question 15

What triad is used for ascending cholangitis?

Answer 15

Charcot

Question 16

What is charcot’s triad and Reynolds’ pentad? What are they used to diagnose?

Answer 16

Charcot triad - RUQ pain, fever, jaundice
Reynold’s pentad - +hypotension, altered GCS

ascending cholangitis

Question 17

A patient has a recent history of biliary colic and acute cholecystitis. She now presents with fever, jaundice and RUQ pain. What is the most likely cause of her presentation?

Answer 17

Question 18

A patient has a recent history of biliary colic and acute cholecystitis. She has not received any treatment thus far. She now reports N+V, acute constant epigastric pain radiating to her back and relieved by leaning forward. Why did this occur?

Answer 18

Question 19

Outline the possible sequelae of a stone in the gallbladder, explaining their symptom presentation.

Go off and include the management if you want but we will go through them separately.

Answer 19

Question 20

What is the ROME criteria and what is it used for?

Answer 20

Question 21

A patient presents with non-specific symptoms. She had an US of her gallbladder and a stone was found. She was then sent for cholecystectomy but her symptoms still persisted. What is the most important ddx that may be causing her symptoms and needs to be ruled out? How is this ruled out?

Answer 21

This is most definitely 100% not the most important diagnosis to rule out 😂😂😂

Question 22

What causes biliary colic? What are the typical symptoms?

Answer 22

Question 23

You are investigating a patient with gallstone disease. What findings would you expect to see on U/S gallbladder?

Answer 23

Question 24

You are investigating a patient with biliary colic. What would you expect to see on LFTs? Why?

Answer 24

Raised ALP due to transient duct occlusion but bilirubin and transaminases.

Question 25

What is the purpose of an MRCP in the case of biliary colic?

Answer 25

Used if stone is unclear on U/s or show a defect in the biliary tree.

Question 26

What investigations would you order to confirm your dx of biliary colic?

Answer 26

Question 27

What is the aim of surgical treatment of biliary colic?

Answer 27

prevent recurrence => more important if recurrent biliary colic

Question 28

A 42-year-old female presents to the emergency department with intermittent right upper quadrant abdominal pain for the past 3 months. History of Present Illness: The pain is described as sharp, colicky, and radiating to the right shoulder blade. Episodes last approximately 1–2 hours and are often triggered by fatty meals. She denies fever, chills, nausea, or vomiting during these episodes. No recent weight loss or changes in bowel habits are reported. Past Medical History: Hypertension (well-controlled on medication). No prior surgeries. Family History: Mother with a history of gallstones. Social History: Non-smoker. Rare alcohol use. Review of Systems: Negative for fever, jaundice, or dark urine. No significant weight loss or anorexia. Physical Examination: Vital signs: BP 125/80 mmHg, HR 78 bpm, Temp 36.8°C. Abdominal exam: Mild tenderness in the right upper quadrant without guarding or rebound tenderness. No palpable masses. Murphy's sign negative. No scleral icterus or jaundice. Initial Laboratory Results: Complete blood count (CBC): Normal. Liver function tests (LFTs): Within normal limits. Lipase: Normal. Imaging: Ultrasound of the abdomen: Gallbladder wall appears normal with no pericholecystic fluid. Multiple small echogenic foci with posterior acoustic shadowing consistent with gallstones are noted. No bile duct dilation. What the management of you likely dx.

Answer 28

Question 29

What is the difference between for ERCP vs MRCP?

Answer 29

ERCP: Best for cases requiring intervention (stone removal, stent placement, biopsy). However, it carries higher risk and should not be used solely for diagnosis unless therapeutic intent is expected. MRCP: Best for non-invasive diagnosis to confirm biliary or pancreatic duct pathology. It is safer and highly sensitive but not therapeutic.

Question 30

What are your ddx for biliary colic?

Answer 30

Question 31

What are the RFs for acute cholecystitis?

Answer 31

Question 32

What is acute cholecystitis? What does this occur?

Answer 32

Question 33

Describe the pathogenesis of acute cholecystitis.

Answer 33

Question 34

Why does acute cholecystitis cause shoulder pain?

Answer 34

phrenic nerve irritation

Question 35

What is Collin's sign in the context of acute cholecystitis?

Answer 35

RUQ Pain radiating to right shoulder due to phrenic nerve irritation.

Question 36

What is Murphy's sign in the context of acute cholecystitis? What does it indicate?

Answer 36

INDICATES LOCAL PERITONITIS

Question 37

List the S+S of acute cholecystitis.

Answer 37

1. RUQ Pain radiating to right shoulder worse after fatty meals do to CCK release 2. n+v 3. tachycardia 3. tachypnoea 4. pyrexia 5. anorexia 6. RUQ tenderness guarding 7. ± jaundice on SBR not clinically (MILD when stone in gallbladder) 8. gallbladder may be palpable 9. murphy's sign ( local peritonism)

Question 38

At what SBR does jaundice becoming a clinical finding? What gallbladder diseases typically cause jaundice?

Answer 38

> 40 mmol/L

Question 39

A patient has all the symptoms of acute cholecystitis but murphy's sign is not positive. What is the likely dx?

Answer 39

Question 40

What lab finding would lead you to suspect there is a stone in the CBD?

Answer 40

Very increased SBR - may be at the level to see clinical jaundice (>40mmol/L)

Question 41

Give the top 3 investigations (+findings on them) to diagnose acute cholecystitis?

Answer 41

Question 42

When is a cholecystectomy performed in the setting of acute cholecystitis? Why?

Answer 42

performed either within 72 hrs or after 6-8 weeks when inflammation settles as the inflammation makes the surgery more difficult (layers of the inflamed organ stick to surrounding structures making it harder to separate and increased the risk of adhesions, also everything looks the same - its all inflamed)

Question 43

When is a percutaneous cholecystostomy used over a cholecystectomy?

Answer 43

Question 44

Outline the management of acute cholecystitis.

Answer 44

Question 45

What are the complications of acute cholecystitis?

Answer 45

Question 46

Cholecystectomies are usually performed laparoscopically. What are the indications for cholecystectomy?

Answer 46

Question 47

Cholecystectomies are usually performed laparoscopically. What are the contraindications for cholecystectomy?

Answer 47

Question 48

Cholecystectomies are usually performed laparoscopically. What are the risks of cholecystectomy?

Answer 48

Question 49

What is a gallbladder empyema? How does it present?

Answer 49

1. RUQ Pain radiating to right shoulder worse after fatty meals do to CCK release 2. n+v 3. tachycardia 3. tachypnoea 4. pyrexia 5. anorexia 6. RUQ tenderness guarding 7. ± jaundice on SBR not clinically (MILD when stone in gallbladder) 8. gallbladder may be palpable 9. murphy's sign ( local peritonism)

Question 50

How do you manage acute cholecystitis complicated by gangrene?

Answer 50

Question 51

How would you investigate for a gallbladder empyema?

Answer 51

same as acute cholecystitis but very increased WCC and CRP Dx - US/CT (better but more radiation)

Question 52

How would you manage a gallbladder empyema?

Answer 52

Pigtail catheter specifically (T-tube only for bile duct pathologies

Question 53

What is gangrene of the gallbladder and how is it diagnosed (2)? Give the specific findings

Answer 53

1) exam: negative murphy’s sign despite all signs and symptoms of acute cholecystitis 2) US showing air within gallbladder (just like in a cholecystoduodenal fistula)

Question 54

What does this image show?

Answer 54

percutaneous cholecystostomy tube

Question 55

What does this image show?

Answer 55

t tube

Question 56

You are operating on a gangrenous gallbladder when the gallbladder is accidentally punctured and spillage begins to complicate the surgery. What was being performed here specifically (im not looking for percutaneous IR drainage).How would you manage this?

Answer 56

Question 57

You are operating on a gangrenous gallbladder. At the start of the surgery, you determine that there is too much inflammation and the surgery needs to be abandoned. What is your action plan for this patient now?

Answer 57

Question 58

How is gangrene of the gallbladder managed?

Answer 58

Question 59

What are the S+S of a perforated Gallbladder?

Answer 59

Question 60

What does this image show?

Answer 60

pigtail catheter drain

Question 61

How would you investigate for a perforated gallbladder?

Answer 61

Question 62

Outline the Management of a perforated gallbladder?

Answer 62

Question 63

What is chronic cholecystitis and what are its key clinical features?

Answer 63

Question 64

How you dx and manage chronic cholecystitis?

Answer 64

Question 65

What are the complications of chronic cholecystitis?

Answer 65

Question 66

What is a mucocele?

Answer 66

Question 67

How does a mucocele present? Why doesn’t Courvoisier’s law apply?

Answer 67

Question 68

What is courvoisier's law?

Answer 68

In a patient with painless jaundice and a palpable, non-tender gallbladder, the cause is more likely to be malignant obstruction of the biliary tree (e.g., pancreatic or biliary cancer) rather than gallstones.

Question 69

How would you manage a mucocele?

Answer 69

Question 70

Where can a gallstone ileus extend to?

Answer 70

Question 71

What is the specific sequelae of a gallstone illeus that is lodged in the duodenum rather than anywhere else? What is this sequelae called?

Answer 71

Bouveret's syndrome - gastric outlet obstruction - intermittent projectile vomiting Typically occurs in elderly with multiple comorbidities and large gallstones (it is a relatively rare phenomenon)

Question 72

What is the sequelae of a gallstone illeus that extends to the terminal ileum?

Answer 72

SBO

Question 73

What is a gallstone ileus?

Answer 73

Question 74

How can a gallstone ileus present?

Answer 74

Question 75

How would you dx gallstone ileus?

Answer 75

Question 76

Outline the management of a gallstone ileus.

Answer 76

Question 77

During laprascopic removal of obstructing stone in the case of a gallstone ileus, is the fistula resected? explain the rationale.

Answer 77

Question 78

What are the causes of obstructive jaundice? Which is the most common cause?

Answer 78

Question 79

How does obstructive jaundice presentation?

Answer 79

Question 80

Why is the gallbladder not palpable in ascending cholangitis?

Answer 80

Question 81

How would you diagnose obstructive jaundice?

Answer 81

Question 82

What is the main surgical technique used to treat obstructive jaundice? Explain the technique! if this technique is difficult to perform, what is the next option?

Answer 82

Question 83

Outline the management of mirizzi syndrome.

Answer 83

It is a laparoscopic cholecystectomy not only removal of the stone

Question 84

What is the indication for t tube use in gallbladder disease? What materials are t tubes made from? Which material should remain in for longer. Why?

Answer 84

Question 85

A patient presenting with obstructive is deemed unfit for ERCP. Why may this be? What is the best treatment option for her?

Answer 85

Reasons for no ERCP: difficult retrieval, surgery along path of ERCP, not fasting, active vomitting, duodenal diverticula.

Question 86

How would you define ascending cholangitis?

Answer 86

Question 87

What are the causes of ascending cholangitis?

Answer 87

Question 88

Explain the pathophysiology of ascending cholangitis.

Answer 88

Question 89

Describe the common presentation of ascending cholangitis.

Answer 89

Question 90

What exam findings would you be looking for in ascending cholangitis?

Answer 90

Question 91

Which of the followings signs is going to present first: pale stools or dark urine? why?

Answer 91

Question 92

What would you expect to find on US gallbladder in ascending cholangitis?

Answer 92

CD dilatation ± stones but not usually seen due to duodenal or intestinal gas.

Question 93

A patient presents with Reynolds’s pentad clearly. On US CBD, there is no evidence of any stones. Why is seeing stones less likely in ascending cholangitis? If the stone is just small, give 3 ways you can get a more accurate picture of the CBD

Answer 93

Stones difficult to see due to excessive amounts of gas and inflammation in the area. Endoscopic US Gallbladder MRCP ERCP

Question 94

Does MRCP involve the use of a contrast?

Answer 94

No static fluids (bile) naturally white on MRCP

Question 95

When is a percutaneous transhepatic cholangiography indicated for investigation of ascending cholangitis?

Answer 95

If T-tube already in situ to look for complications Or If MRCP/ ERCP has failed.

Question 96

What would you see on MRCP in ascending cholangitis?

Answer 96

stone will show a filling defect.

Question 97

How would you investigate for ascending cholangitis?

Answer 97

Question 98

Outline the management of ascending cholangitis. Include the indications and step up management.

Answer 98

Question 99

What is the most common site for cholangiocarcinoma? Where does it metastasise to?

Answer 99

Question 100

What would you find on histopathology of cholangiocarcinoma?

Answer 100

usually adeno

Question 101

What are the RFs for cholangiocarcinoma?

Answer 101

Question 102

What are the tumour markers for cholangiocarcinoma?

Answer 102

Ca19-9, CEA

Question 103

How would you investigate for cholangiocarcinoma?

Answer 103

same as before (image) + staging via CT

Question 104

Can a patient with biliary disease and jaundice have bilious vomitting?

Answer 104

no cause no bile

Question 105

What are the complications of cholangiocarcinoma?

Answer 105

Question 106

Outline the management of cholangiocarcinoma.

Answer 106

Question 107

What is the main complication of a mucocele?

Answer 107

If a mucocele gets infected, it causes gangrene which will liquify => -ve murphy sign and no more rigid RUQ mass

Question 108

What is the normal width of the gallbladder? What would be considered distended? What is normal GB wall thickness? What would be considered thickened? What is the normal diameter of the CBD What is considered dilated?

Answer 108

GB width Normal 3-4cm Distended is >6cm GB wall thickness Normal is <3mm Thickened >4mm CBD diameter Normal <6 (unless post-cholecystectomy, then <10) Dilated >6

Question 109

What are the findings on US that will hint towards gallstone disease

Answer 109

1) Acoustic shadowing (or gallstones) 2) Large gallbladder >6cm 3) Dilated CBD proximal to obstruction >6mm (in most) 4) GB wall thickening >4mm 5) Pericholecystic fluid 6) Sonographic Murphy's sign

Question 110

What is the diameter of a normal bile duct?

Answer 110

<6mm Note after cholecystectomy normal becomes under 1cm

Question 111

A patient presented with acute cholecystitis and has been treated appropriately. They are sent home and booked an elective cholecystectomy in 6 weeks. Youve explained it to the patient and are giving safety netting advice to come back if symptoms develop. What is the risk that the patient comes back?

Answer 111

Within the 6 week timeframe, there is a 30% risk of another attack