Gastro2 Flashcards

Question

If a patient with biliary colic demonstrates gall bladder polyps on ultrasound?

Answer 1

If there were gall bladder polyps found on the ultrasound, it would be recommended that Omar have ultrasonography performed every six months for two years to ensure that there is no growth beyond 10 mm ( A polyp greater th 20mm increases risk of malignancy and requires cholecystectomy at over 10mm If patient has IBD or PSC - then any polyps are risky and need to be removed

Answer 2

non adenomatous are usually less than 10 mm and represent cholesterol deposits and can be watched and managed with elective cholecystect if sypmtpms persist ADenomatous are rare - over 20mm increases risk of malignancy but if over 10mm needs cholecystectiomy

Answer 3

Likely cholangitis and need IV abx as well as biliary decompression through and ERCP

Answer 4

Increased bleeding risk and so does ERCP and temporary plastic stenting (sometimes omitting stone removal and sphincterotomy) REmoval of stent at two months - then stone removal and sphincterotomy

Answer 5

If the obstruction is above the common bile duct but below the intrahepatic ducts, the most likely cause is **Mirizzi syndrome.** This occurs when a large gallstone becomes impacted at the cystic/bile duct junction and occludes the common hepatic duct, leading to biliary obstruction. The differential diagnosis is a malignancy of the gall bladder or bile ducts. **Cross-sectional imaging with a CT scan or magnetic resonance imaging** is useful to exclude features of malignancy. Management of Mirizzi syndrome is usually complex. A **cholecystectomy c**an sometimes be performed to resolve the situation. However, there is often severe inflammation of the bile duct, or even fistula between the common bile duct and gall bladder. Other management approaches, including a **partial or subtotal cholecystectomy** with or without biliary procedures, are commonly undertaken. **Decompression of the infected biliary tree is mandatory, and this is usually achieved through biliary stenting.** In rare cases, **bile duct reconstruction using biliary-enteric anastomosis is required.**

Answer 6

In the meantime, management comprises analgesia and avoidance of fatty foods. It is worth reminding patients that fatty foods include ‘healthy’ fats such as avocado, nuts and olive oil. Analgesia for biliary colic includes paracetamol, nonsteroidal anti-inflammatory drugs and, in some cases, opiates if other choices have not proven effective. Some patients report symptomatic relief with antispasmodics.

Answer 7

1. Referral for expedited cholecystecomy 2. Analgesia - PCM, NSAIDS, Antispasmodics 3. Safety netting - emergency dept if uncontrolled pain,vomiting, dehydration or jaundice 4. Avoidance of fatty foods (including good fatS)

Answer 8

1. , Lap chole is ok in any trimester 2. Open chole only ok in 2nd trimester. 3. Radiation may be an issue with ERCP and may need intraop choledocoscopy instead 4. Discuss with obs and gastro re: risk/benefit. sometimes wait till after preg if only mild disease pregnancy in any term is not an absolute contraindication for cholecystectomy.2 There should be a conversation with the managing obstetric team and the surgical team about the patient, and risks and benefits need to be weighed. For instance, a mild, single attack of biliary colic might be managed conservatively until after birth, whereas acute cholecystitis or choledocholithiasis might be managed with surgery. The use of intra-operative radiation should be minimised; if it is required, there should be shielding of the fetus in place. This sometimes means that an intraoperative choledochoscopy will be used in preference to ERCP to clear common bile duct stones if present.

Answer 9

time off work - one week off sedentary work, no heavy lifting for six weeks wound management - dressings can be removed after one week, can swim once scab replaced by dry scar (usually at 3 weeks) - monitor signs of infection driving - dont drive if under influence of opiate meds - usually ok to drive after a few days diet - monitor for diarrhoea pain control. - pcm/nsaids may need short course of opiate nanalgesic. iF persists needs investigation - bile leak? postcholecystectomy syndrome -eg sphincter of oddi dysfunction -needs gastro referral

Gastro2 Flashcards

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