Gallbladder and billary tree

Question 1

What bile stored in Gallbladder composed of ?

Answer 1

70 % Bile salts 
10 % Cholesterol 
5 % Phospholipids 
5 % Proteins 
1% Bilirubin ( 98 -99 % conjugated , 1 -2 % unconjuagted )
electrolytes ex - CA2 +
Bicarbonate

Question 2

What are Gallstones ?

Types 
Causes 
Who is at greater risk 
   - ethnicity 
   - Gender

Answer 2

Can be made out of the contents of the Gallbladder e.g.

0 Bilirubin gallstone ( pigmented stones )
       - Too much 
         Bilirubin - 
         it the 
    unconjugated 
    form that 
    binds. 
        binds with 
        CA to form 
        Calcium 
   BILIRUBINATE 
      - visible on X 
        ray

causes - extravascular Haemolysis - RBC broken more than usual ——-> increased UCB release ——–> increase in CB ( this increase is seen in the bile as well as for UCB ) - UCB free to bind to calcium and form the stone.

0 Cholesterol Gallstone - 75 -90 % - CANT BE SEEN ON X RAY - (But if they have enough CACO3 they cab be seen. ) - but not as common

• WOMEN AT GREATER RISK OF Cholesterols stones —– oestrogen increases formation of stones —– use of oral contraceptives containing oestrogen - increases risk

Obesity —- > increased cholesterol —> increase risk of C stone development

Rapid weight loss ——> reduced lipids ——> increased risk ( do with less phospholipoid ? )

cholesterol precipitated out and formed solid stone.
- causes - supersaturation of cholesterol in bile———–> so bile salts and phospholipoid cannot hold any more in solution ( bile salts / phospholipids help to make cholesterol more soluble in bile )———–> Cholesterol comes out of solution ( precipitates )

or
* not enough bile salts / phospholipids in solution so cholesterol not kept in solution and precipitates out.

or

Gallbladder stasis - bile sits there and cholesterol precipitates out.

Brown pigmented stones - sign of biliary tract or gallbladder infection

• present in gallbladder or bile duct.

Made up of Calcium and UCB.

• ex - bacteria invades gallbladder etc ——-> brings hydrolytic enzymes along with it———> Hydrolyse CB to UCB & hydrolyse Phospholipid ———-> UCB + CA2 = brown stone. brown because of mix of UCB + Phospholipid.

example bacterias

0 E. Coli
0 Ascaris Lumbericoides

0 Clonorcnis sinesis - endemic to
0 Asian Populations - brown stones more common in this community.

Question 3

What is Acute Cholecystitis ?

Answer 3

Inflammation of Gallbladder —> caused by obstruction of cystic duct by gallstones.

(MOST COMMON COMPLICATION OF Cholelithiasis - presence of one or more gallstone )

gallstone in the gallbladder can be asymptomatic .
It is when then obstruct the cystic duct - it causes problems .

Question 4

What is Choledocholithiasis ?

Answer 4

Formation of gallstones in common bile duct .

Question 5

How do Biliary colic , Acute cholecystitis and Cholangitis differ ?

Answer 5

Biliary Colic - temporary obstruction by gallstone at neck of gallbladder

0 Presents with RUQ pain. - shorter duration , less severe ( compared to AC) vs acute cholecystitis - (> 6 hours ) -

Cholangitis - complication of gallstones - infection develops. - LIFE THREATENING

Presents with ;
    - RUQ pain
      - Fever / 
       Raised 
       WBC count
      - Jaundice
   ( Charcot's 
      triad

Acute Cholecystitis

0 Presents with 
      - RUQ pain
      - Fever 
      - Raised 
       WBC count

RUQ pain
Frever / EBC increased

Jaundice

Question 6

Symptoms / signs of Acute Cholecystitis ?

Answer 6

RUQ pain
pain which may radiate to right side of shoulder , right scapular or around upper abdomen.
Fever
Vomiting

Murphy sign - on examination (O.E ) deep inspiration during palpation of RUQ exacerbates pain - halting inspiration)

• during inspiration the diaphragm moves down and we are pressing on the mid border of liver - irritates gallbladder —–> trigger pain —–> patent stops breathing in.

Question 7

Complications of Gallstones ?

Answer 7

0 Gallstone carcinoid

0 Mucocele - mucous secreted into gallbladder

0 Chronic Cholecystitis

0 Empyema - pus in gallbladder due to infection.

0 Mirizzi’s syndrome - impacted gallstone in cystic duct compresses hepatic duct ——->(Cholestasis - interuption / bloackage to bile flow from liver ) BILE produced by liver goes backwards to liver ——–> causes obstructive jaundice

0 Perforation of gallbladder

0 Cholecystroenteric fistula (Gallbladder - duodenal fistula ) - large gallstone erodes gallbladder wall —–> fistula created into small bowel or somewhere else in Abdominal cavity.

• fistula - abnormal connection btw 2 body parts.

0 large gallstones pass through and cause gallstone ileus at terminal ileus ( Gallstone ileus )

• ileus - lack of movement in the intestine

0Gallstone Pancreatitis - gallstone blocks duct where the pancreatic + common bile duct join ——> contents of pancreatic duct cannot pass e.g autodigestion etc. - radiation of pain to back.

Backflow to liver - obstruction of common bile duct ——-> obstructive jaundice.

• obstructive jaundice - jaundice - dark urine ,pale stools.

peritonitis - inflammation of peritoneum

Question 8

What is Courvoisier’s Law ?

Answer 8

Enlarged Gallbladder + painless jaundice ———–> more likely to be carcinoma at the head of pancreas rather than Gallstones.

Question 9

Treatment of Acute Cholecystitis ?

Answer 9

Asymptomatic - no surgery

Symptomatic - Cholecystectomy - open / Laparoscopic

• cystic duct & artery clipped —–> incision made btw clips ( clipped to prevent spillage of contents ) —-. gallbladder safety removed.

Question 10

Treatment of Acute Cholecystitis ?

Answer 10

Asymptomatic - no surgery

Symptomatic - Cholecystectomy - open / Laparoscopic

Laparoscopic - 3 holes made.
- cystic duct & artery clipped —–> incision made btw clips ( clipped to prevent spillage of contents ) —-. gallbladder safety removed. ——> peritoneum closed.

Question 11

What is Acalculous Cholecystitis ?

Risk factors

Answer 11

Cholecystitis without gallstones . less common but often more serious.

ACCOUNTS FOR 5 - 10 % - OF Cholecystitis .

most often caused by biliary stasis or gallbladder ischemia .

RISK FACTORS

• critical illness
• Prolonged fasting
• Shock
• Immune deficiency
• Vasculitis ( e.g. systemic lupus erythematous , polyarteritis nodose - inflammation of small + medium sized arteries preventing them from bringing 02 to organs —–> secondary tissue ischemia. ( most commonly - KIDNEYS , SKIN , JOINTS , MUSCLES , GI TRACT)

Symptoms
- similar to Acute cholecytosis - difficult to identify as Patients may be severely ill - ITU

Unexplained fever and abdominal distention - may be only clue.

untreated can rapidly lead to gallbladder gangrene , perforation —–> sepsis , shock , peritonitis.

Question 12

Differential diagnosis of Gallstones ?

Answer 12

0 Acute hepatitis —

0 Bile duct stricture.

0 Gallbladder polyps.

0 Gastritis

0 Gastro-oesophageal reflux disease — Dyspepsia - proven GORD.

0 Inflammatory bowel disease

0 Irritable bowel syndrome

0 Non-biliary acute pancreatitis — 0 Pancreatitis - acute.

0 Peptic ulcer disease —
Dyspepsia - proven peptic ulcer.

0 Tumours of the gallbladder, liver, stomach, gut, and pancreas

Question 13

Management of Asymptomatic gallstones ?

Answer 13

0 Asymptomatic gallstones in gallbladder - no treatment

Prophylactic Cholecystectomy - not recommended - complications outweigh risk.

0 Asymptomatic gallstones in common bile duct - Offer bile duct clearance + Laparoscopic cholecystectomy - significant risk of serious complications e.g Cholangitis / pancreatitis.

Question 14

Management of symptomatic gallstones ?

Answer 14

Symptomatic gallstones

0 Systemically unwell with suspected complication - ( AC , Cholangitis , pancreatitis ) - admit to hospital - emergency.

0 Patients with known gallstone + jaundice or suspicion of biliary obstruction - urgent referral to gastroenterology / surgeon.

0 All other diagnosed symptomatic gallstone disease refer for laparoscopic cholecystectomy .

• urgency of referral dependant on clinical judgement.

Secondary care options - early LC (within 1 week of diagnosis )

Symptomatic gallstone in bile duct - LC + bile duct clearance

While waiting for secondary care appointment -
PAIN RELIEF -

SEVERE PAIN
intramuscular Diclofenac 75mg , second dose after 30 mins if needed.

opioid intramuscularly e.g morphine , pethidine - if diclofenac contraindicated/ not suitable/ not working (in this case can be used with diclofenac. )

MILD - TO MODERATE INTERMITTENT PAIN

NSAID - DICLODENAC - oral / rectal

if pain not managed in primary care refer to hospital.

consider recommended low fat diet to hep with biliary pain.

Question 15

Diagnosis of Gallstones /

Answer 15

Abdomainal ultrasound - confirm presence ( absence does not exclude their existence )

LFT - gallstone sin bile duct may result in abnormal LFT

Further investigatio n :

1. MRCP - magnetic resonance cholangiopancreatography
   
   • done if ultrasound does not detect but :
     bile duct dilated
     LFT abnormal
2. Endoscopic Ultrasound (EUS ) - MRCP - still no diagnosis.

( can also a FBC , Amylase / Lipase (pancreatitis ) , LFT , CRP , EUC - to find out what is wrong - could be something else.

Question 16

What does the length of RUQ pain tell you?

Answer 16

Shorter than 30 mins - likely to something else.

more than 30 mins , less than 8 hours - biliary colic

> 8 hours - acute cholecystitis

Question 17

What is Courvoiser’s Law ?

Answer 17

If the gallbladder is palpated and their is jaundice it is unlikely to due to gallstones . OBSTRUCTIVE CARCINOMA MORE LIKELY.

this is because if there are gallstone ————————> chronic inflammation of gallbladder —————–> fibrosis of gallbladder ( fibrosis means it is no longer able to distend so would not be palpable. )