Gallstones and Cholestasis

Question 1

Describe risk factors for the development of gallstone

Answer 1

age >40yo
sex F>M
pregnancy
OCP/estrogen
rapid weight loss
crohn's disease (altered enterohepatic circulation)
hemolysis

Question 2

What are the constituents of bile?

Answer 2

water, bile acids, phospholipids, electrolytes, cholesterol, bilirubin

Question 3

What factors increase biliary stone formation?

Answer 3

increased cholesterol, decreased solubilizing bile salts leads to supersaturation

crystal nucleation along with bile stasis of bile salt, phophliopid and cholesterol leads to bile stones

Question 4

Contrast the composition of cholesterol and pigmented stones.

Answer 4

pigmented stones are primarily composed of calcium bilirubinate

Question 5

When is cholecystectomy indicated?

Answer 5

SYMPTOMATIC cholelithiasis
acute cholecystitis (risk of perforation and gangrene)
chronic cholecystitis
porcelain gallbladder

Question 6

What are the findings of acute cholecystitis?

Answer 6

fever, RUQ pain, elevated WBC LFTs
CT: thickened gallbladder and pericholecystic fluid

chronic has a more indolent course, still with distended thickened GB and cholethiasis almost always

Question 7

Why is porcelain gallbladder significant?

Answer 7

up to 30% risk of gallbladder, often in the setting of chronic cholecysititis

Question 8

Most likely dx?

55yo obese male with previous cholecystectomy 5y ago and RUQ pain, mildly elevated WBC and elevated bilirubin/alk phos.

Answer 8

choledocholithiasis gallstones in common bile duct, hepatic duct etc., confirm with MCP or ERCP– think colic pain due to “ball valve effect”

complications include acute cholangitis and gallstone pancreatitis

Question 9

In the context of gallbladder disease, what is the cause of severe constant epigastric pain?

Answer 9

gallstone pancreatitis, confirm with peripancreatic inflammation, dilated bile ducts

tx is IV fluids, medically stabilize then ERCP to remove stone

Question 10

What are Charcot’s triad?

Answer 10

RUQ pain, fever, jaundice –> acute choleangitis

Question 11

What is the management of acute choleangitis?

Answer 11

IV fluids, abx, lab assessment and imaging

probable ERCP/PTC for biliary

Question 12

What do you add to Charcot’s triad to get Reynold’s pentad?

Answer 12

hypotension

mental status changes

Question 13

What bacteria are often causative agents in Cholangitis?

Answer 13

E. coli, Klebsiella, enterobacter species (normal bowel flora)