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Year 3 Hepatobiliary surgery > Gallstones > Flashcards

Gallstones Flashcards

1
Q

Gallstone contents

A
  • Phospholipids
  • Bile pigments (broken down Hb) - associated with haemolysis - sickle cell anaemia
  • Cholesterol
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2
Q

Risk factors for gallstones (5Fs)

A
  • Female
  • Fat
  • Fertile - OCP, pregnancy
  • Forty +
  • FHx
  • Loss of terminal ileum (↓ bile salts)
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3
Q

Complications of gallstones in the gall bladder

A
  • Biliary Colic
  • Acute cholecystitis ± empyema
  • Chronic cholecytsitis
  • Mucocele
  • Carcinoma
  • Mirizzi’s syndrome
  • Fistula
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4
Q

Mirizzi’s syndrome

A

Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder

Ix - MRCP
Mx- laparoscopic cholecystectomy.

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5
Q

Biliary colic

A

Gallbladder spasm against a stone impacted in the neck of the gallbladder – Hartmann’s Pouch

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6
Q

Presentation of gallstones

A

Biliary colic

  • sudden dull RUQ pain radiating to back (scapular region)
  • Associated with sweating, pallor, n/v
  • Aggravated by fatty food and last <6h
  • o/e may be tenderness in right hypochondrium
  • ± jaundice if stones passes in to CBD
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7
Q

Acute cholecystitis sign

A

Murphy’s sign +ve

  • when palpating RUQ, painful when inhaling
  • -ve on left
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8
Q

Investigations for gallstones

A
  • Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP
  • Urine: bilirubin, urobilinogen, Hb
  • Imaging
  • AXR: 10% of gallstones are radio-opaque
  • Erect CXR: perforation
  • Transabdo USS (first line)

• If diagnosis uncertain after USS - HIDA cholescintigraphy: shows failure of GB filling
(requires functioning liver)

• If dilated ducts seen on USS → MRCP (gold standard)

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9
Q

Treatment of gallstones

A

• Conservative

  • Low fat diet, exercise
  • Monitor LFTs: passage of stone spontanously
  • Give vitamins ADEK
  • Analgesia - morphine
  • Cholestyramine - bile acid sequestrant preventing reabsorption
  • Rehydrate

Surgery:
If no resolution, worsening LFTs or cholangitis:
- ERCP with sphincterotomy and stone extraction

Offered within 6 weeks of first presentation:
- Laparoscopic cholecystectomy

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10
Q

Acute cholecystitis

A
  • Stone impaction in Hartmann’s pouch or cystic duct

* chemical and/or bacterial inflammation

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11
Q

Sequelae of acute cholecystitis

A
  • Resolution ± recurrence
  • Gangrene and rarely perforation
  • Chronic cholecystitis
  • Empyema
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12
Q

Presentation of acute cholecystitis

A 
• Severe RUQ pain
- Continuous
- Radiates to right scapula and epigastrium
• Fever
• Vomiting
Examination:
• Local peritonism in RUQ
• Tachycardia with shallow breathing
• ± jaundice
• Murphy’s sign
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13
Q

Investigations for acute cholecystitis

A

•Bloods

  • FBC: ↑ WCC
  • U+E: dehydration from vomiting
  • Amylase, LFTs, G+S, clotting, CRP
  • Urine - bilirubin, urobilinogen
  • Imaging
  • AXR: gallstone, porcelain gallbladder
  • Erect CXR: perforation
  • USS - 1st line
  • If the diagnosis is uncertain after USS - HIDA cholescintigraphy which shows failure of GB filling (requires functioning liver)
  • MRCP if dilated ducts seen on USS (gold standard)
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14
Q

Management of acute cholecystitis

A

Conservative:

  • NBM
  • Fluid resuscitation
  • Analgesia: paracetamol, diclofenac, codeine

Medication:
- Abx: cefuroxime and metronidazole

Surgical

  • Elective laparoscopic cholecystectomy surgery - within 1 week
  • <72h ideal
  • percutaneous cholecystostomy - if not fit for surgery and not responding to abx
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15
Q

Chronic Cholecystitis

A 
Symptoms: Flatulent Dyspepsia
• Vague upper abdominal discomfort
• Distension, bloating
• Nausea
• Flatulence, burping
• Symptoms exacerbated by fatty foods
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16
Q

Investigations for Chronic Cholecystitis

A
  • AXR: porcelain gallbladder
  • USS: stones, fibrotic, shrunken gallbladder
  • MRCP
17
Q

Mx of chronic cholecystitis

A

Mx
• Medical
- Bile salts (not very effective)

• Surgical

  • Elective cholecystectomy
  • ERCP first if US shows dilated ducts and stones
18
Q

Mucocele

A

Neck of gallbladder blocked by stone but contents remains sterile
• Can be very large → palpable mass
• May become infected → empyema

19
Q

Gallstone ileus

A

Stone impacts at the terminal ileum causing small bowel obstruction

20
Q

Rigler’s Triad

A

Pneumobiliia
Small bowel obstruction
Gallstone in RLQ

21
Q

Bouveret’s syndrome

A

Obstruction of proximal duodenum by a gall- stone in the gallbladder causing duodenal obstruction

22
Q

Ascending Cholangitis

A
  • Obstruction of common biliary duct with infection
  • Charcot’s triad:
  • fever/rigors
  • RUQ pain
  • jaundice
  • Reynolds pentad: Charcot’s triad + shock + confusion
  • Mx
  • urgent drainage if sepsis
  • abx - Cef and met
  • 1st: ERCP
  • 2nd: Open or lap stone removal
23
Q

Pigment stones

A

Commonly seen in those with known haemolytic anaemia

24
Q

USS findings

A
  • Stones: acoustic shadow
  • Dilated ducts (>6mm)
  • Inflamed GB: wall oedema
25
Q

Gallbladder Empyema

A

Gallbladder becomes filled with pus - can lead to sepsis and cause RUQ pain and fever

Ix - USS
Mx - laparoscopic cholecystectomy

26
Q

Cholecysto-duodenal fistula

A

Fistula between gall bladder and small bowel

27
Q

Causes of cholangitis

A

Gallstones
ERCP - iatrogenic
Cholangiocarcinoma

Rare:
Pancreatitis
PSC

28
Q

Common organisms in cholangitis

A

Escherichia Coli - most common
Klebsiella
Enterococcus (15%)

29
Q

Investigations for ascending cholangitis

A

Abdo exam
Routine bloods - leucocytosis + raised ALP

Blood cultures

USS - 1st line
MRCP - gold standard

30
Q

Mx of ascending cholangitis

A

1st line: ERCP

2nd line: PTC - percutaneous transhepatic cholangiography

Year 3 Hepatobiliary surgery (7 decks)

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