HPB

Question 1

What is Bile formed from?

Answer 1

Cholesterol, Phospholipids and Bile pigments

Question 2

Where is bile stored?

Answer 2

Gallbladder

Question 3

Why do Gallstones form?

Answer 3

Due to a supersaturation of bile

Question 4

What are the different types of gallstone?

Answer 4

Cholesterol Stones
Pigment Stones
Mixed Stones

Question 5

How are Cholesterol stones formed?

Answer 5

Formed from excess cholesterol, linked to poor diet and obesity

Question 6

How are Pigment stones formed?

Answer 6

Formed from bile pigments due to an excess pigment production

Question 7

What are Mixed gallstones formed of?

Answer 7

A mixture of Cholesterol and Bile pigments

Question 8

What are some risk factors for Gallstone disease?

Answer 8

The 5 Fs
Pregnancy
Oral contraceptives
Haemolytic anaemia
Malabsorption conditions

Question 9

What are the 5 Fs in relation to gallstones?

Answer 9

Fat
Female
Fertile
Fourty
Family Hx

Question 10

What is Biliary colic?

Answer 10

Condition when the gallbladder neck becomes impacted with a gallstone. There are no features of inflammation, however can have pain due to contraction of the neck against the stone

Question 11

How is the pain often described in biliary colic?

Answer 11

Sudden
Dull
Colicky

Question 12

Where is the pain felt in biliary colic?

Answer 12

RUQ

Can radiate to Epigastrium +/- Back

Question 13

What can often trigger biliary colic?

Answer 13

Consumption of fatty foods

Question 14

What are the management options for biliary colic?

Answer 14

Analgesia - Paracetamol +/- NSAIDs. Opioids if needed
Lifestyle modifications
Surgery

Question 15

When should a Laparoscopic Cholecystectomy be offered with biliary colic?

Answer 15

Within 6/52 of initial presentation, due to risk of recurrence/complications

Question 16

What is Acute Cholecystitis?

Answer 16

Inflammation of the gallbladder due to stone impaction

Question 17

How does Acute Cholecystitis present?

Answer 17

Constant RUQ pain
Signs of inflammation - Lethargy, fever
Murphy’s +ve

Question 18

What are some other possible differentials with Acute Cholecystitis?

Answer 18

GORD
Peptic Ulcer disease
Acute pancreatitis
IBD

Question 19

What abnormalities may be present in bloods with Acute Cholecystitis?

Answer 19

Raised CRP

Raised ALP

Question 20

Which imaging is first-line with suspected Acute Cholecystitis?

Answer 20

USS

Question 21

What does USS demonstrate in acute cholecystitis?

Answer 21

Presence of gallstones/sludge
Increased gallbladder wall thickness
Bile duct dilatation

Question 22

When should an MRCP be performed with suspected Acute Cholecystitis?

Answer 22

If USS is inconclusive

Question 23

What are the management steps for acute cholecystitis?

Answer 23

IV Abx - Co-Amoxiclav +/- Metronidazole
Analgesia and Antiemetics
Laparoscopic Cholecystectomy within 1 week
Percutaneous drainage if unsuitable for Lap Chole

Question 24

What is Mirizzi Syndrome?

Answer 24

A stone in the cystic duct compresses the common hepatic duct giving obstructive jaundice

Question 25

What can gallbladder inflammation lead to?

Answer 25

Formation of a cholecystoduodenal fistula allowing gallstones to pass directly to small bowel

Question 26

What is Bouveret's Syndrome?

Answer 26

Stone impaction in proximal duodenum causing a gastric outlet obstruction

Question 27

What is Gallstone ileus?

Answer 27

Stone impaction at the terminal ileus giving small bowel obstruction

Question 28

What is Cholangitis?

Answer 28

Infection of the biliary tree due to a combination of biliary outflow obstruction and biliary infection

Question 29

Why does biliary obstruction lead to Cholangitis?

Answer 29

Stasis of fluid combined with elevated intraluminal pressure allows for bacterial colonisation of the biliary tree to become pathological

Question 30

What are some common causes of cholangitis?

Answer 30

``` Gallstones ERCP Cholangiocarcinoma Pancreatitis Primary Sclerosing Cholangitis ```

Question 31

What are the common causative organisms of Cholangitis?

Answer 31

E. Coli Klebsiella Enterococcus

Question 32

What are some clinical features of Cholangitis?

Answer 32

``` RUQ Pain Fever Jaundice Pyrexia Rigors Hypotension ```

Question 33

What is Charcots Triad in relation to Cholangitis?

Answer 33

Pain Fever Jaundice

Question 34

What is Reynolds Pentad in relation to Cholangitis?

Answer 34

``` Jaundice Fever RUQ Pain Hypotension Confusion ```

Question 35

What may bloods demonstrate in Cholangitis?

Answer 35

Raised ALP, Gamma GT and Bilirubin

Question 36

What is the gold-standard imaging for suspected Cholangitis?

Answer 36

ERCP

Question 37

What is the appropriate management of Cholangitis?

Answer 37

IV Abx | Systemic Support/Sepsis management

Question 38

How can Cholangitis be treated?

Answer 38

ERCP +/- Sphincterotomy/Stenting