what is the medical term for the presence of solid concentrations in the gallbladder?
cholelithiasis
when do gallstones cause symptoms?
when they get stuck in the cystic, common or pancreatic bile duct
what are the types of gallstones?
pure cholesterol (10%)
Pure pigment (bile salts, 10%)
- black = associated with haemolytic disease
- brown = associated with chronic cholangitis
mixed (80%)
what predisposes to gallstones?
female, fair, fertile, fat and forty
- increased age
- female
- obesity
- multiparity
- haemolytic disorders
- long term TPN
what are the S&S of gallstones?
RUQ or epigastric pain
- biliary colic
- postprandial (esp fatty foods)
- tenderness on palpation
- lasts >30 mins
Dyspepsia, flatulence, bloating
what InV are done in gallstones?
Abdominal US
- stones in gallbladder
LFTs
- normal
MRCP
what are the treatment options for gallstones?
observation if tolerable symptoms
If symptomatic
- Analgesia
- anti-spasmodic e.g hyoscine
- cholecystectomy
what is cholangitis?
an infection of the biliary tree, most commonly caused by obstruction due to gallstone deposition in the biliary tree
what are the S&S of cholangitis?
RUQ pain
- typically diffuse
- NO murphy’s sign - NO NO NO
- tenderness on palpation
Jaundice
- dark urine and pale stool
- yellow skin and pruritis
Fever and Nausea
what is Charcot’s triad?
used for diagnosis of cholangitis based on symptoms
- severe RUQ pain
- obstructive jaundice
- high swinging fever
what InV are done for suspected cholangitis?
FBC
- leucocytosis
- thrombocytopenia
U&E’s, LFTs, creatinine
- increased urea and creatinine in severe disease
- increased bilirubin, transaminitis and Alk P
- possible hypokalaemia and hypomagnesaemia
increased CRP
Transabdominal US
- dilated bile ducts and CBD stones
MRCP
ERCP if patient cannot tolerate MRCP or intervention needed
what is the management of cholangitis?
Analgesia
- morphine
IV fluids
IV ABx
- piperacillin/tazobactam OR Amox/Gent
ERCP with stone removal and drainage stent placement
Lap choledochotomy if above fails
what is acute cholecystitis?
Acute inflammation of the gallbladder for which GB stone obstruction of the cystic duct is the cause in 90%.
what are the S&S of acute cholecystitis?
RUQ pain
- severe and constant
- may radiate to the back or shoulder
RUQ tenderness
- Murphys sign
palpable mass
fever, N&V and anorexia
jaundice in only 10%
what is Murphy’s sign?
pain on palpation of RUQ during deep inspiration that is not present on the left
what InV are done in acute cholecysitis?
Abdo US
- pericholecystic fluid
- distended GB
- thickened GB wall
- Gallstones
CT/MRI abdo
- irregular thickening of GB wall
- poor contrast enhancement of GB wall - interrupted rim sign
- gas in GB lumen or wall
FBC and CRP
- increased WCC and CRP
LFTs and bilirubin
- increased bilirubin, ALP, ALT and GGT
amylase
- rule out pancreatitis
what is the management of acute cholecysitits ?
analgesia
- paracetamol, diclofenac or morphine depending on pain
IV fluids
IV Abx - typically amox and Gent, add met is severe
cholecystectomy or percutaneous cholecystostomy (drain) if patient unfit for surgery
what are the complications of acute cholecystitis?
empyema or abscess of GB
perforation with biliary peritonitis
cholecystenteric fistula formation
