GallStones + Biliary tree Flashcards
Causes of GS
80% cholesterol 20% pigmented, (mostly mixed)
Female, Fourty, Fertile(many kids), Fat.
Black pigment: Ca biliruminate, Haemolytic disease.
Brown stones: Ca salts from FFAs & Ca bilirubinate)
Cause of bile stasis & biliary infx
Pigment stones; chronic haemolysis eg hereditary spherocytosis and sickle cell disease- bilirubin production ⬆️ and also in cirrhosis.
‼️‼️CAN ALSO FORM IN BILE DUCTS AFTER CHOLECYSTECTOMY and w/ duct strictures.
Differential diagnosis
Acute pancreatitis, perforated ulcer, intrahepatic abscess, basal pneumonia, M iscaemia, colon spasm, renal colic (R kidney)
Where do GS form?
GB
Cholesterol gall stones only form in bile where there is a deficiency of phospholipids or Xs of cholesterol. (Super saturated or lithogenic bile) - favour- nucleation factors- mucus and Ca2+ .
GS formation further promoted by stasis, and ⬇️ GB motility.
Cholesterol Gall stones RF
Age
F
Fhx
Obesity
Rapid weight loss
Diet ⬆️ in animal fat
Ileal disease or resection - not absob B12? Fats
DM
Drugs (HRT (Xs Ca2+), OCP, octreotide, ceftriaxone)
Acromegaly treated with octreotide
Liver cirrhosis (no bile salts? More cholesterol?)
Gall stone complications
Impacted in cystic duct: Acute cholecystitis-> empyema, Gangrene, Perforation.
Causing biliary obstruction in CBD: ascending cholangitis, Cholestatic jaundice.
Pancreatic duct: gallstone pancreatitis .
Gallstone ileus.
Acute cholecystitis
Cystic duct or neck of GB.
Rare- w/o GS- acalculus cholecystitis.
CF
Initial: similar to biliary colic
H/w after hours–> progression to severe pain w/ localised RUQ p assc w/ fever and tenderness + muscle guarding.
Tenderness worse on inspiration- Murphys sign.
Complications- empyema, perforation w/ peritonitis.
Inv- WCC- leukocytosis ⬆️⬆️
Serum LFTs- mildly abnormal
Radiology: Dx by USS- dilatation GS + distended GB w/ thickened wall + sonographic murphys sign.
Mx
NBM, IV fluids, analgesia + IV antibiotics- cefotaxime.
Cholecystectomy only if complications develep -48hrs from acute attck.
Biliary pain
Colic- temporary obstructiom of cystic or CBD by stone.
CF
Recurrent episodes of sever constant pain in upper abdo, subsides after hours.
Assc w/ vomitting.
Invx
Dx- hx and USS showing GS.
LFTs : ⬆️⬆️ ALP + ⬆️⬆️ bilirubin during attack support dx.
Mx
Analgesia and elective cholecystectomy.
Abnormal liver biochem or dilated CBD or stone on ultrasonography is an indication for pre-op MRCP and/or ERCP.
Where does the pain radiate in biliary colic?
Right shoulder and right subscapular region
How do we differentiate acute cholecystitis from biliary pain?
Abscence of inflamatorry features: fever, WCC and local peritonism
Chronic cholecystitis
Chronic inflammation often in assc w/ gs.
Cholecystectomy not indicated
Chronic R gypochondrial pain and fatty food intolerance are likely to be functional and Gs incidentaly found.
Acute cholangitis
Biliary tree infx , B commonest. Human bile. NOrmally sterile.
Biliary obstruction impairs bile flow- gut microorganisms.
CBD stones (choledolithiasis) commonest cause.
Other causes:
Benign biliary strictures following biliary surgery or assc w/ chronic pancreatitis, Primary sclerosing cholangitis (PSC), HIV cholangiopathy + in pts w/ biliary stents.
Bile duct obstruction due to head of pancreas cancer or cholangiocatcinoma (CBD cancer) –> cholangitis esp after ERCP.
Mediterranean- biliary parasites.
CF:
Classic: fever, jaundice and RUQ pain. Smts fever w/ rigors.
Jaundice: cholecystatic- so dark urine, pale stools, skin itches.
Elderly: non spepific sx- malaise and confusion.
Invx
WCC- leukocytosis
Blood cultures +ve - E.coli, E.faecalis, smts anaerobes in 30%.
Liver biochem: cholesistatic pic: ⬆️ALP+ ⬆️ bilirubin.
USS- dilated CBD and may show obstruction cause.
Abdo CT- asses site and cause????
ERCP- ⭐️ definite invx- will allow biliary drainage, indicates site and cause of obstruction - bile can be sampled for cyrology and culture, if malignant cause suspected.
Mx
Resuscitation + volume replacement in shocked pts , pain relief and IV antibiotics + relief of obstruction by biliary drainage.
Suitable refimne:
3rd generation cephalosporin eg cefotaxime or ciprofloxacin if allergic + metronidiazole.
Alternative regimne:
Amoxicillin+ gentamycin (monitor)+ metronidiazole.
Endemic areas: 1o parasite infxs must be treated !
Antibiotics continued after biliary drainage until sx resolution :7-10D
What is Charcots triad?
What disease ??
fever, jaundice and RUQ pain. (Charcot’s triad)
Acute cholangitis
Are GS seen on USS?
Yes in GB
In CBD- dilatation is shown. No stones.
How is biliary drainage achieved?
+ biliary clearance- ERCP w/ or w/o sphincterectomy.
Urgency of this depends on clinical condition and response to antibiotcs. Stones can be removed or a stent placed if not, or to relieve obstruction in cancer patients (head and CBd) .
Choledolithiasis
CBD stones
Can be asx, with abnormal liver biochem - cholestatic pic- ⬆️ALP + ⬆️ bilirubin.
USS will show stones or CBD containing them.
Endoscopic USS more sensitive than transabdo, so performed if high index suscpicion and all other are -ve.
MRCP- alternative non-invasive tech for imaging biliary system.
