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Flashcards in Surgical Management of the Gallbladder Deck (22)
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1

What is the cause of gallstones?

What are the risk factors?

  • Derangement of biliary chemistry.
  • Female sex.
  • Getting older.
  • Being fertile or on the oral contraceptive pill. 
  • Family history. 
  • Obesity 

2

How do gallstones present?

  • Many are asymptomatic - most people do not get abnormal LFTs.
  • Biliary colic
  • Biliary dyspepsia
  • Acute cholecystitis
  • CBD stones / jaundice
  • Acute pancreatitis
  • Gallstone ileus - presents with small bowel obstruction

3

What is gallstone ileus?

A gall stone becomes lodged in the small bowel.  

4

Describe cholecystitis.

  • A stone becomes trapped in the cystic duct. 
  • Bile cannot be ejected from the gallbladder and it stagnates. 
  • The stagnated bile irritates the gallbladder mucosa which (in response) secretes mucous and inflammatory enzymes.
  • This results in distension and pressure build-up in the gall bladder. 
  • This is cholecystitis.

5

What are the characteristics of biliary colic?

  • Severe pain in RUQ / epigastrium. 
  • Lasting minutes or hours. 
  • May radiate to the back or chest (? IHD).
  • Often nausea or vomiting. 
  • Usually settles spontaneously. 
  • Recurrence may be associated with fat intake. 
    • If patients eat less fat they get fewer episodes of biliary colic and are systemically okay.

  • Minimal systemic upset. 

6

What are the symptoms and signs of acute cholecystitis?

  • ? History of biliary colic.
  • More presistent pain.
  • RUQ tenderness (? Murphy's sign).
  • May have systemic pointers (↑ T, ↑ WBC, ↑ CRP).
  • More unwell, likely to be admitted. 

7

How should biliary colic be managed?

  • Analgesia
  • Low fat diet
  • Elective surgery if patient is seriously troubled
  • ?Stone dissolution

8

How should acute cholecystitis be managed?

  • IV fluids
  • Antibiotics
  • Analgesia
  • Urgent investigation
  • Surgery if fit and common bile duct is clear

9

Which investigations should be carried out on a patient who has ? acute cholecystitis?

  • LFTs, amylase (anyone with upper abdominal pain should have acute pancreatitis excluded).
  • USS scan.
  • ? MRCP (magnetic resonance cholangiopancreatography).
  • General fitness.

10

How are common bile duct stones are managed?

  • ERCP (Endoscopic retrograde cholangiopancreatography) for most. 
  • At operation (laparoscopic or open).

11

What are the complications of ERCP?

  • Acute pancreatitis
  • Bleeding
  • Perforation

12

What are the symptoms of obstructive jaundice?

  • Jaundice; itching
  • Painful or painless
  • Dark urine 
  • Pale stools
  • ? Fever

13

What are the causes of obstructive jaundice?

  • CBD stones
  • Benign biliary stricture
  • Intrahepatic / PBC
  • Malignancy

14

How should obstructive jaundice be managed?

  • Blood tests including liver screen.
  • Imaging USS, usually followed by CT and/or MRCP.
  • ERCP +/- stent, or stone removal.
  • Endoscopic US +/- biopsy. 

15

What is Charcot's triad?

  • RUQ pain and tenderness
  • Obstructive jaundice
  • Fever +/- rigors

16

How should a patient be managed if they present with Charcot's triad?

  • Medical emergency.
  • IV fluids and antibiotics.
  • Close monitoring on HDU.
  • Biliary decompression once well enough. 
  • Most commonly related to common bile duct stones. 

17

What areas can be affected by biliary malignancy?

  • Bile duct
  • Gall bladder
  • Ampulla
  • Pancreas

18

What are the risk factors for bile duct cancer?

  • Primary sclerosing cholangitis
  • Common bile duct stones
  • Liver fluke infection
  • Cirrhosis
  • Hepatitis

19

What are the risk factors for pancreatic cancer?

  • Age
  • Smoking
  • Obesity
  • Diabetes
  • Pancreatitis
  • Gallstones or gallbladder surgery
  • ? Alcohol

20

How is pancreatic cancer staged?

  • CT
  • EUS
  • Biopsy if accessible

21

How should pancreatic cancer be managed?

  • Surgery if possible
  • Biliary stent
  • (Bypass surgery)

22

What is the outlook for patients with pancreatic cancer?

  • Reasonable outlook for patients with ampullary cancer (30-50% 5 year survival). 
  • Very poor otherwise