Cholecystitis

Question 1

Types of gall stones

Answer 1

1. Pigmented: hemolysis
2. Cholesterol: large->+age, obesity
3. Mixed: calcium salt + cholesterol 90% asymptomatic

Question 2

Risk factors cholecystitis

Answer 2

1. Calculous

Cholesterol gall stones: Female, fat, forty, fertile, pregnant, OCP, rapid weight loss

Pigmented gall stones: hemolytic disease, salmonella, infection

2. Acalculous (stasis)

Severe illness, sepsis

Cardiac

TPN, prolonged fasting

Physical inactivity

Low fibre

Trauma

Severe burns

Ceftriaxone

Infections

3. Other

Sickle cell

Diabetes

AIDS->CMV, cryptococcus

Question 3

Clinical features

Answer 3

RUQ pain

Previous biliary pain

+ve murphy’s

Abdominal mass

Right shoulder pain,

Anorexia, nausea, fever, vomiting

Question 4

Investigations

Answer 4

FBC->+WBC

CRP->elevated

LFTs->elevated ALP, GGT, bilirubin

Amylase->pancreatitis

RUQ USS->pericholecystic fluid, distended gall bladder, thickened wall, +ve murphy’s sign

Question 5

Criteria

Answer 5

1. Local signs of inflammation
2. Systemic signs of inflammation->fever, CRP, WCC
3. Imaging findings

Question 6

Management

Answer 6

1. ABC, assess severity
2. NBM
3. IVF, investigations->FBC, UEC, CRP, USS, AXR/ECXR (depending on presentation)
4. Antibiotics: Gentamicin + amoxycillin
5. Analgesia (diclofenac) + antiemetic
6. Monitoring->BP, pulse/RR, urinary output
7. Surgical consult
8. Admit, book and consent . Complete pre-op workup
9. Laparoscopic cholecytectomy within 48 hours

Question 7

USS findings

Answer 7

1. Bright echoic with acoustic shadowing
2. Thickened wall
3. Halo 4. May show stones, dilation of the duct

Question 8

When in ERCP indicated

Answer 8

1. Not in uncomplicated gall stone disease
2. Recurrent biliary pain/pancreatitis when gall stones suspected of being underlying cause but not identified on USS

Question 9

Possible clinical situations with gall stones

Answer 9

1. Incidental gall stones on USS
2. Incidental at laparotomy
3. Biliary colic 4. Cholecystitis
4. Obstructive jaundice
5. Cholangitis
6. Gallstone ileus
7. Pancreatitis
8. Mucocele/empyema
9. Mirizzi’s
10. Perforation

Question 10

Management of incidental gall stone on USS, cumulative incidence of requiring a lap chole

Answer 10

1. Unless evidence of biliary pain- do nothing
2. Cumulative incidence of requiring a lap chole is 1% per year

Question 11

Management when incidental at laparotomy

Answer 11

1. +risk of becoming symptomatic, 75% at 12 months
2. If adequate exposure, tolerating anaesthesia, can add cholecystectomy and cholangiography

Question 12

Management of biliary colic

Answer 12

1. Once pain, increased risk of ongoing
2. At 5 years, all will have recurrence and 20% will develop a complication
3. Unless operative risk ++, or low life expectancy operation
4. Analgesia, hydration, NBM, elective cholecystectomy

Question 13

Pre-operative treatment

Answer 13

1. Fasting
2. Prophylactic Antibiotics->cefazolin
3. DVT prophylaxis

Question 14

Post operative when laparoscopic

Answer 14

1. 2 weeks until return of activity
2. Less pain and ileus
3. Ambulant day of surgery
4. Narcotics 1 day, simple oral analgesia for 10 days

Question 15

Post-operative when open

Answer 15

1. ++Pain
2. DVT prophylaxs
3. 5 day hospital stay
4. PCA
5. NBM for 24-48 hours->+ileus
6. IVF two days
7. Four weeks until normal return of activity

Question 16

Specific complications

Answer 16

1. Bile duct injury->suspect if ongoing pain and fever, LFTs immediately->if +cholangiogram required
2. Persistent/recurrent biliary pain->retained stone, SOO dysfunction, wound neuragial, nerve injury, original pain not due to gall stone

Question 17

Acalculous

Answer 17

Gallbladder inflammation caused by biliary stasis (in 5% of patients with acute cholecystitis) leading to gallbladder distension, venous congestion, and decreased perfusion; it nearly always occurs in patients hospitalized with a critical illness.

Question 18

Cholangitis

Answer 18

1. Infection within the bile ducts, most commonly caused by complete or partial obstruction of the bile ducts by gallstones or strictures.
2. The classic Charcot triad (RUQ pain, jaundice, and fever) is seen in only 70% of patients.
3. This condition may lead to life-threatening sepsis and multiple-organ failure.
4. Treatment consists of antibiotic therapy and supportive care; in cases of severe cholangitis, endoscopic decompression of the bile duct by endoscopic retrograde cholangiopancreatography (ERCP) or surgery is indicated.

Question 19

Biliary dyskinesia investigation

Answer 19

1. Obtain a CCK-stimulated HIDA (hepatobiliary iminodiacetic acid) scan When typical features of biliary colic, with negative USS of stones