gallstones (see DM)

Question 1

what is bile composed of (5)

Answer 1

1. water (97%)
2. bile acids/salts
3. bile bigments - biliverdin, bilirubin
4. lipids - cholesterol, fatty acids, phospholipids
5. electrolytes

Question 2

what are the functions of bile (6, top two are the major ones)

Answer 2

1. emulsification of fats - allow for greater SA for enzyme activity
2. neutralises gastric secretions
3. absoption of fats and fat-soluble vitamins (ADEK)
4. excretion of substances e.g. bile pigments, excess cholesterol
5. laxative and lubrication for chyme
6. bacteriocidal

Question 3

what are the 3 main types of gall stones

Answer 3

1. cholesterol stones - due to excess cholesterol production
2. pigment stones - purely comprised of bile pigments, may arise due to haemolytic anaemaia
3. mixed - mixture of the two

Question 4

why might gallstones not be seen on x-rays

Answer 4

most don’t contain enough calcium to appear opaque on xray

Question 5

what are the 5 Fs of gallstones (epidemiology)

Answer 5

1. fat
2. female
3. fertile
4. forty
5. family history

Question 6

what is a complication of gallstones due to vitamin malabsoption

Answer 6

clotting disorder -> vit K needed in clotting factor synthesis

Question 7

what conditions may predispose a pt to gallstones (4)

Answer 7

1. cystic fibrosis
2. cirrhosis
3. impaired gall bladder emptying
4. haemolytic anaemia

Question 8

where does the common bile duct drain into

Answer 8

the duodenum

Question 9

what are some common areas that gallstones can cause blockages at (3)

Answer 9

1. cystic duct
2. common bile duct
3. convergence of common bile and pancreatic duct

Question 10

where can gallstones cause complications

Answer 10

1. in the gall baldder (choleithiasis)
2. in the biliary system (choledocholithiasis)
3. outside the biliary system (e.g. GI tracts)

Question 11

complications of gallstones (8)

Answer 11

1. biliary colic
2. cholecystitis
3. mirizzi syndrome (common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder)
4. obstructive jaundice
5. ascending cholangitis
6. acute obstructive suppurative ascending cholangitis
7. pancreatitis
8. gallstone ileus

Question 12

what is bilary colic

Answer 12

spasm of cystic duct due to calculi causing blockages

Question 13

what precipitates bilary colic

Answer 13

large fatty meal

Question 14

biliary colic presentation

Answer 14

RUQ pain

Question 15

biliary colic investigations + findings (2)

Answer 15

1. bloods - normal
2. US - gallstones, thin walled gall bladder

Question 16

biliary colic mgx (2)

Answer 16

1. analgesia
2. elective cholecystectomy

Question 17

what is cholecystitis

Answer 17

inflammation of the gall bladder -> progression of biliary colic leading to inflammation

Question 18

cholecystitis presentation (3)

Answer 18

1. RUQ pain
2. murphy’s sign (unable to complete full inspiration when palpating due to pain)
3. fever

Question 19

cholecystitis investigations + findings (2)

Answer 19

1. bloods - raised WCC, CRP, normal LFTs
2. USS - gallstones, thick-walled gallbladder

Question 20

cholecystitis mgx (5)

Answer 20

1. Abx - broad spectrum (amoxicillin, gentamicin and metraniazole)
2. analgesia
3. “hot” cholecystectomy (Laparoscopic Cholecystectomy during an acute attack)
4. delayed cholecystectomy (after abx etc.)
5. cholecystostomy (drainage of gall bladder)

Question 21

what is mirizzi syndrome

Answer 21

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

Question 22

what can mirizzi syndrome progress to form

Answer 22

a fistula

Question 23

mirizzi syndrome investigations + results (3)

Answer 23

1. bloods- raised WBC, CRP, obstructive LFTs (raised ALP and GGT)
2. US - gallastones, thick walled gallbladder, dilated intrahepatic ducts
3. MRCP

Question 24

mirizzi syndrome mgx (3)

Answer 24

1. abx
2. analgesia
3. complex surgical mgx

Question 25

obstructive jaundice presentation (2)

Answer 25

1. jaundice 2. RUQ pain (if due to gall stones)

Question 26

what is Courvoisier's law

Answer 26

if a pt has jaundice and a painLESS enlarged gall bladder it is most likley NOT due to gallstones but some other underlying cause e.g. pancreatic malignancy

Question 27

obstructive jaundice investigations and results

Answer 27

1. bloods - obstructive LFTs (raised ALP and GGT) 2. US - dilated common bile duct +/- intrahepatic ducts 3. MRCP

Question 28

obstructive jaundice mgx

Answer 28

dependent on cause 1. Endoscopic retrograde cholangiopancreatography (ERCP); 2. cholecystectomy with CBD exploration

Question 29

what is ascending cholangitis

Answer 29

biiliary stasis in obstructive jaundice leading to infection

Question 30

ascending cholangitis presentation (4)

Answer 30

1. jaundice 2. RUQ pain 3. fever 4. charcot's triad (pain, fever, jaundice/rigors)

Question 31

ascending cholangitis investigations and results (3)

Answer 31

1. bloods - obstructive LFTs, raised WBC, raised CRP 2. US - dilated common bile duct +/- intrahepatic ducts, thickening of bile duct walls 3. MRCP

Question 32

what is suppurative cholangitis

Answer 32

accumulation of pus in the bile ducts - may lead to increased intrabiliary pressure and sepsis

Question 32

ascending cholangitis mgx

Answer 32

1. abx 2. resusitation 3. biliary tree decompression - ERCP

Question 33

suppurative cholangitis presentation (5)

Answer 33

1. jaundice 2. RUQ pain 3. fever 4. hypotension 5. mental obtundation (aka reynold's pentad -> pain, obstructive jaundice, fever, hypotension, mental change)

Question 34

suppurative cholangitis investigations

Answer 34

1. bloods - obstructive LFTs, raised WCC, raised CRP 2. US - dilated common bile duct +/- intrahepatic duct 3. MRCP

Question 35

suppurative cholangitis mgx

Answer 35

1. abx 2. resuscitation 3. organ support 4. intensive care 5. ERCP

Question 36

pancreatitis presentation

Answer 36

epigastric pain that radiates to the back and is better on leaning forward

Question 37

pancreatitis investigations and findings

Answer 37

1. bloods - amylase >100 or x3 higher than upper limit of normal, or lipase 2. US - gallstones 3. CT abdo + pelvis

Question 38

pancreatitis mgx

Answer 38

1. supportive care (possibly intensive care) 2. cholecystectomy (in uncomplicated cases), can be done immediately or 2 weeks post discharge

Question 39

what is gallstone ileus

Answer 39

small bowel obstruction caused by an impaction of a gallstone within the lumen of the small intestine due to the formation of a cholecysto-enteric fistula

Question 40

gallstone ileus presentation (3)

Answer 40

1. vomiting 2. constipation 3. hx of RUQ pain

Question 41

gallstone ileus investigations and findings (3)

Answer 41

1. bloods - may be normal 2. XR/CT - aerobilia, bowel obstruction, gallstones at ileocaecal junction (aka Rigler triad) 3. CT abdomen/pelvis - rigler triad

Question 42

what is the rigler triad in gallstone ileus

Answer 42

1. small bowel obstruction 2. aerobilia - gas within the biliary tree 3. gallstones (usually in the right iliac fossa)

Question 43

gallstone ileus mgx

Answer 43

1. resusitation 2. NG tube - drain fluid from stomach 3. enterolithotomy - the extraction of a stone through an enterotomy, without performing a procedure to resolve the fistula or the gallbladder disease

Question 44

what is seen in the US of someone w a gallstone (2)

Answer 44

1. high attenuation og the gall stone itself 2. acoustic shadow below gallstone

Question 45

what is a porcelain gall bladder

Answer 45

calcification of the gallbladder wall