Biliary colic + Cholecystitis

Question 1

If thinking cholecystitis but need to think about other GI conditions, what to check for on exam?

Answer 1

• Jaundice - sclera first
• Cullen and Grey turners sign - retroperitoneal bleeding
• AAA - pulsatile mass?
• Murphys sign - palpate below rib in RUQ, ask patient to take deep breath in, if catches breath = +ve as gall bladder hits hand when moves down on inspiration
• Distended - obstruction?
• Lieing still - peritonitis?

Question 2

Anatomy of bile ducts

Answer 2

Question 3

Indications for surgery for gallstones

Answer 3

• Biliary colic - EC within 6 weeks of first presentation
• Cholecytsitis - within 1 week of presentation BUT better if within 72hrs
• Cholangitis - ERCP
• Mirizzi syndrome - LC
• Gallbladder empyema - LC
• Chronic cholecystitis - elective

EC = elective cholecystectomy, LC - laparascopic cholecystectomy

Question 4

Pathophys of gallstones

Answer 4

• Cholesterol, phospholipids and bile pigments = bile
• Gallstones form due to supersaturation of bile
• Can be cholesterol stones, pigment stones or mixed
• Cholesterol = excess so poor diet, obesity
• Pigment = excess bile pigment seen in haemolytic anaemia

Question 5

RF for gallstones

Answer 5

5 F’s
* Female
* Fat
* Fertile
* Forty
* FH
* Others inc pregnancy, oral contraceptives, haemolytic anaemia and malabsorption (eg Crohns or ileal resection)

OC - oestrogen increases cholesterol secretion into bile

Question 6

Biliary colic

Answer 6

• Gallbladder neck impacted by stone
• No inflammatory response
• Contraction of gallbladder = pain
• Sudden, dull and colicky
• Precipitated by fatty foods (CCK released as fatty acids stimulate duodenum to release)

Imagine it floating and then getting trapped in neck when GB contracts

Question 7

Acute cholecystitis presentation

Answer 7

• Constant pain RUQ
• Signs of inflammation eg fever/lethargy
• Can have +ve Murphys sign and tender RUQ

Question 8

Bloods for biliary colic and cholecystitis

Answer 8

• FBC and CRP - inflammatory response?
• LFTs - raised ALP?
• Amylase/lipase - pancreatitis?
• Urinalysis inc pregnancy test

Question 9

Imaging for biliary colic/cholecystitis suspect

Answer 9

• Trans-abdominal USS - FIRST LINE
• If inconclusive, can do MRCP - defects in biliary tree

Question 10

What does trans-abdominal USS scan show if gallstone disease present?

Answer 10

• Presence of gallstones or sludge (start of GS)
• Gall bladder wall thickening - if inflammation
• Bile duct dilatation - if stone present distally

Question 11

Biliary colic management

Answer 11

• Analgesia - paracetamol, +/- NSAIDs +/- opiates
• Weight loss, low fat, increase exercise
• Elective laparascopic cholecystectomy - within 6 weeks of first presentation

Question 12

Acute cholecystitis management

Answer 12

• IV abx eg co-amoxiclav +/- metronidazole
• Analgesia and antiemetics
• Laparascopic cholecystectomy within 1 week BUT ideally within 72hrs of presentation

Question 13

Acute cholecystitis surgery if not suitable for LC and not responding to abx

Answer 13

• Percutaneous cholecystostomy - drain infection
• BUT risk of recurrent disease remains as stones remain

Like nephrostomy but gallbladder

Question 14

RUQ pain post cholecystectomy cause?

Answer 14

• Exclude retained CBD stone
• US abdomen needed
• MRCP may be needed if this is inconclusive

Question 15

Complications of gallstones

Answer 15

• Mirizzi syndrome
• Gallbladder empyema
• Chronic cholecystitits
• Bouverets syndrome
• Gallstone ileus

Question 16

What is Mirizzi syndrome?

Answer 16

• Stone located in Hartmanns pouch (outpouching of GB wall at the junction of cystic duct) OR in cystic duct
• Can then compress common hepatic duct
• = obstructive jaunduce even without stones being in CBD or common hepatic duct
• Need lap cholecystectomy

Question 17

What is gallbladder empyema?

Answer 17

• Gallbladder becomes filled with pus
• Patients become unwell, septic
• Similar presentation to acute cholecystitis
• BUT significant mortality and morbidity
• US scan or CT scan with lap cholecystectomy

MAY need intra-op drainage of GB if tense

Question 18

Chronic cholecystitits

Answer 18

• Recurrent/untreated cholecystitis
• Ongoing RUQ or epigastric pain
• Associated N+V
• Diagnose by CT imaging
• Elective cholecystectomy

Complications inc gallbladder carcinoma and biliary enteric fistula

Question 19

What is Bouveret’s sundrome and gallstone ileus?

Answer 19

• Inflammation can cause fistula to form between GB and small bowel
• Cholecystoduodenal fistula
• So can get bowel obstruction if stones pass into bowel
• Bouverets - proximal duodenum blockage causing gastric outlet problem
• Gallstone ileus - terminal ileum = SBO