Gallstones Flashcards
(120 cards)
1
Q
What are gallstones?
A
Gallstones are small stones that form in the gallbladder
2
Q
What happens in most cases of gallstones?
A
They don’t cause symptoms, and can remain untreated
3
Q
What can happen if a gallstone becomes trapped in a duct?
A
It can cause biliary colic and other complications
4
Q
What do gallstones contain?
A
- Cholesterol
- Bile pigments
- Phospholipids
5
Q
What happens if the concentrations of different constituents of gallstones vary?
A
Different stones can form
6
Q
What is the prevalence of gallstones in those over 40 years?
A
8%
7
Q
What are the risk factors for the gallstones becoming symptomatic?
A
- Smoking
- Parity
8
Q
What are bile pigments?
A
Products of haemoglobin metabolism
9
Q
Where is bile stored?
A
In the gallbladder
10
Q
What happens to bile on gallbladder stimulation?
A
It passes into the duodenum
11
Q
When do gallstones develop?
A
When bile contains too much cholesterol and not enough bile salts
12
Q
What other factors are important in gallstone formation?
A
- How ofetn and well the gallbladder contracts
- Presence of proteins in liver and bile that either promote or inhibit cholesterol crystallisation into gallstones
13
Q
How is how often and well the gallbladder contracts important in the development of gallstones?
A
Infrequent or incomplete emptying can cause the bile to become over-concentrated and lead to gallstone formation
14
Q
How is oestrogen involved in gallstones?
A
It has been found to increase cholesterol levels in bile and decrease gallbladder movement, resulting in gallstone formation
15
Q
What are the types of gallstones?
A
- Pigment stones
- Cholesterol stones
- Mixed stones
16
Q
What are pigment stones?
A
Small, friable stones
17
Q
What causes pigment stones?
A
Haemolysis
18
Q
What are cholesterol stones?
A
Large, often solitary stones
19
Q
What are the risk factors cholesterol stones?
A
- Female gender
- Age
- Obesity
20
Q
- Fat
- Female
- Fertile
- Forty
- Family history
- Pregnancy and oral contraceptives
- Haemolytic anaemia
- Malabsorption, e.g. ileal resection, Crohn’s disease
A
21
Q
Why do pregnancy and oral contraceptives increase the risk of gallstones?
A
Because oestrogen causes more cholesterol to be secreted into bile
22
Q
How are most gallstones discovered?
A
Most are asymptomatic, and picked up incidentally on ultrasound scans, most commonly a trans-abdominal ultrasound
23
Q
What investigations are done in gallstones?
A
- Liver function tests
- Ultrasound
- Consider MRCP
- Blood tests
- Urinalysis
24
Q
Who should LFTs and ultrasound be offered to?
A
All people with suspected gallstone disease
25
When should MRCP be considered in gallstones?
If ultrasound didn't detect common bile duct stones, but the bile duct is dilated or LFTs are abnormal
26
What should urinalysis in gallstones include if female?
Pregnancy test
27
Why is urinalysis done in the investigation of gallstones?
To exclude any renal or tubo-ovarian pathology
28
What is the first line imaging in gallstones?
Trans-abdominal ultrasound
29
Why is transabdominal ultrasound first line in investigation of gallstones?
Because it is one of the most sensitive modalities for visualising gallstone disease
30
What might trans-abdominal ultrasound show in gallstones?
* Presence of gallstones or sludge
* Gallbladder wall thickening
* Bile duct dilation
31
What does gallbladder wall thickening indicate?
That inflammation is likely
32
What does bile duct dilation indicate?
A possible stone or stricture in the distal bile ducts
33
What blood tests are done in the investigation of gallstones?
* FBC and CRP
* U&Es
* LFTs
* Amylase
34
What might FBC and CRP show in gallstones?
May show evidence of an inflammatory resposne
35
When might gallstones cause an inflammatory response?
In biliary pathology such as cholecystitis, cholangitis, and pancreatitis
36
Why should U&Es be done in gallstones?
Assess for any dehydration secondary to reduced oral fluid intake
37
What may be shown on LFTs in gallstones?
Biliary colic and acute cholecystitis likely to show raised ALP, indicating ductal occulsion, yet other parameters should remain within normal ranges
38
Why should amylase be checked in suspected gallstones?
Check for pancreatitis
39
When is no treatment required for gallstones?
When a person has asymptomatic gallstones found in a normal gallbladder
40
When should a person with asymptomatic gallstones be treated?
If they are in the common bile duct
41
Why should a person with asymptomatic gallstones in the common bile duct be treated?
Because that person is at high risk of developing serious complications such as cholangitis or pancreatitis
42
How should a person with asymptomatic gallstones in the common bile duct be managed?
Same as a person with symptomatic gallstones
43
What are the symptomatic presentations of gallstones?
* Biliary colic
* Acute cholecystitis
* Chronic cholecystitis
* Obstructive jaundice
* Cholangitis
* Gallstone ileus
* Pancreatitis
* Mucocoele/empyema
* Mirizzi’s syndrome
* Gallbladder necrosis
44
What is biliary colic?
When gallstones become symptomatic with cystic duct or common bile duct obstruction
45
How does biliary colic present?
Sharp RUQ pain, with or without jaundice
46
Where does the pain in biliary colic radiate to?
The back or right shoulder
47
How long does the pain last in biliary colic?
Often lasts longer than 30 minutes, up to a few housr
48
What other symptoms may be associated with biliary colic?
Nausea and vomiting
49
What might the pain follow in biliary colic?
A fatty meal and the symptom of indigestion
50
How should suspected biliary colic be investigated?
* FBC
* LFTs
* Lipase
* Urinalysis
* CXR
* ECG
51
How is biliary colic initially managed?
* Analgesia
* Lifestyle factors
52
What analgesia should be prescribed in biliary colic?
Typically NSAIDs and PRN opiods, *along with an appropriate antiemetic*
53
What analgesic does NICE recommend for severe pain in biliary colic?
Diclofenac 75mg IV, *unless contraindicated*
54
What can be used in severe pain caused by biliary colic when diclofenac is unsuitable or ineffective?
IM opioids, e.g. morphine
55
What analgesia should be offered for intermittent mild to moderate pain in biliary colic?
Paracetamol or oral NSAID
56
What should be done if there is no improvement with analgesia in biliary colic?
Consider possibility of cholecystitis
57
How are lifestyle factors involved in the management of biliary colic?
Patients should be advised about lifestyle factors that may help control symptoms and help with future surgery
58
What lifestyle changes should be made in the management of biliary colic?
* Low fat diet
* Weight loss
* Increasing exercise
59
What should be provided at discharge for biliary colic?
PRN analgesia
60
What is likely following the first presentation of biliary colic?
There is a high chance of symptom recurrence or development of complications
61
What are the complications of biliary colic?
* Cholecystitis
* Acute pancreatitis
62
What is done as a result of the high chance of recurrence/complications in biliary colic?
An elective cholecystectomy should be offered
63
How long after presentation should an elective cholecystectomy be offered?
Ideally within the first 6 weeks of presentation
64
What surgical technique is used for cholecystectomy?
A laproscopic route is preferred, but not always possible
65
What is acute cholecystitis?
Inflammation of the gallbladder that develops over hours
66
What does acute cholecystitis usually result from?
A stone or sludge impaction in the neck of the gallbladder
67
What are the symptoms of acute cholecystitis?
* Pain
* Vomiting
* Fever
* Local peritonism
* Gallbladder mass
68
Describe the pain in acute cholecystitis
It is continuous epigastric or RUQ pain, which may refer to the right shoulde r
69
What can happen in acute cholecystitis if the stone moves to the CBD?
Obstructive jaundice and cholangitis may occur
70
What investigations are done in acute cholecystitis?
* Examination
* FBC
* Ultrasound
* Plain AXR
71
What are the examination signs in acute cholecystitis?
* Murphy's sign
* May be able to palpate a phlegmon
72
How is Murphy's sign detected?
By lying two fingers over the RUQ, and asking the patient to breath in
73
What is a positive Murphy's test?
Pain and arrest of inspiration *as the inflamed gallbladder impinges on fingers*
Must also perform test in the LUQ, as positive result requires no pain on this side
74
What is a phlegmon?
A RUQ mass of inflamed adherent omentum and bowel
75
What may the ultrasound show in acute cholecystitis?
* Thick-walled, shrunken gallbladder
* Pericholecystic fluid
* Stones
* Dilated common bile duct (\>6mm)
76
What % of gallstones can be seen on plain AXR?
About 10%
77
What might a plain AXR show in acute cholecystitis?
A 'porcelain' gallbladder
78
What is a 'porcelain' galbladder associated with?
Risk of cancer
79
How should patients with acute cholecystitis be managed initially?
* Started on appropriate IV antibiotics
* Fluid resuscitation
* NG tube
* Concurrent analgesia
80
What antibiotics can be given in acute cholecystitis?
Co-amoxiclav, with or without metronidazole
81
What should be done if a patient with acute cholecystitis demonstrates evidence of sepsis?
Management should be adapted accordingly
82
When should a NG tube be placed in acute cholecystitis?
If the patient is vomiting and made NBM
83
What analgesia should be prescribed in acute cholecystitis?
Typically simple analgesics and PRN opioids, *and anti-emetics*
84
What is the definitive management for acute cholecystitis?
Laparoscopic cholecystectomy
85
When should a laparoscopic cholecystectomy be performed in acute cholecystitis?
Within 1 week, however ideally within 72 hours of presentation
86
Why are earlier cholecystectomies preferred in acute cholecystitis?
Because they are safe, and reduce overall hospital stay
87
When is a percutaneous cholecystectomy performed?
In patients not fit for surgery and not responding to antibiotics
88
What is the purpose of a percutaneous cholecystectomy?
To drain the infection
89
What should the patient be advised of after a percutaneous cholecystectomy?
Lifestyle changes
90
What will patients with chronic cholecystitis typically have a history of?
Recurrent or untreated cholecystitis
91
What does recurrent or untreated cholecystitis lead to?
Chronic inflammation of the gallbladder wall
92
What are the symptoms of chronic cholecystitis?
May be asymptomatic, or symptoms may include;
* Vague abdominal discomfort
* Distention
* Nausea
* Flatulence
* Fat intolerance
93
What are the differential diagnoses for chronic cholecystitis?
* Hiatus hernia
* IBS
* Peptic ulcer
* Chronic pancreatitis
* Tumour
94
How is chronic cholecystitis investigated?
* Ultrasound
* MRCP
95
What is the purpose of ultrasound in the investigation of chronic cholecystitis?
To image stones and assess CBD diameter
96
What is the purpose of MRCP in chronic cholecystitis?
To image CBD stones
97
How is chronic cholecystitis managed?
Cholecystectomy
98
How is chronic cholecystitis managed if US shows dilated CBD with stones?
ERCP and sphincterectomy before surgery
99
What are the complications of chronic cholecystitis?
It conveys an increased risk of gallbladder carcinoma and biliary-enteric fistula
100
What is gallbladder empyema?
When the gallbladder is infected and an abscess forms within it
101
How do patients with gallbladder empyma typically present?
Patients are typically septic, and present with a similar-type picture to acute cholecystitis
102
What is gallbladder empyema associated with?
Significant morbidity and mortality
103
How is gallbladder empyema diagnosed?
US scan or CT scan
104
How is gallbladder empyema treated?
Laparoscopic cholecystectomy
105
What may be required intra-operatively in gallbladder empyema if there is a tense gallbladder?
Intra-operative drainage
106
How does the rate of conversion to open cholecystectomy in gallbladder empyema compare to uncomplicated acute cholecystitis?
It is higher
107
How can gallbladder empyema be managed if the patient is suitable for surgery?
Percutaneous cholecystomy
108
What can inflammation of the gallbladder, typically if recurrent or silent, cause?
A fistula to form between the gallbladder wall and the duodenum
109
What does a fistula between the gallbladder and duodenum allow?
Gallstones to pass into the small bowel
110
What can gallstones passing into the small bowel via a fistula cause?
Bowel obstruction
111
Give two conditions whereby a fistula leads to a gallstone causing bowel obstruction
* Bouveret's syndrome
* Gallstone ileus
112
What happens in Bouveret's syndrome?
When a stone impacts to cause duodenal obstruction
113
What happens in a gallstone ileus?
The stone impacts to cause obstruction at the terminal ileum (the narrowest part of the adult bowel)
114
What is ascending cholangitis also known as?
Acute cholangitis, or just cholangitis
115
What is ascending cholangitis?
An infection of the bile duct
116
What causes ascending cholangitis?
Typically caused by bacteria ascending from the junction with the duodenum
117
When does ascending cholangitis tend to occur?
When the bile duct is already partially obstructed by gallstones
118
Is ascending cholangitis regarded as a medical emergency?
Yes, it can be life threatening
119
What are the symptoms of ascending cholangitis?
* Jaundice
* Fever
* Abdominal pain
* In severe cases, low blood pressure and confusion
120
How is ascending cholangitis managed?
* IV fluids and antibiotics
* Treatment of underlying condition
