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8 Cards in this Set
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A 51 year-old woman presented to the Emergency Department with an eight hour history of severe upper abdominal pain which radiated around to her back and was associated with nausea and vomiting. On examination she was distressed by the pain, with tachycardia, fever, and tenderness in the right upper quadrant (RUQ). She had a past history of episodic epigastric pain, which on one occasion was accompanied by jaundice. Pdx? |
PDx: Acute cholecystitis DDx: Acute pancreatitis, biliary cholic, choledocholitiasis, cholangitis (charcot's triad not present), hepatitis, PUD, oesophagitis, GORD, pyelonephritis
Non gastro: AMI, AAA, aortic aneurysm, LL pneumonia |
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What are relevant history and examination findings? |
Pain: - Radiation to right scapula - Association with meals i.e. avoidance of fatty food N+V Stools: Diarrhoea, pale stools, dark urine
Examination: Murphy's sign, guarding, rigidity, |
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What are the types of cholecystits? What is the anatomical and pathological basis of her current presentation? |
Pain worsened on this occasion due to the impaction of a stone at the cystic duct leading to cholecystitis (inflammation of the gallbladder wall)
Calculus cholecystitis 1. Obstruction caused trauma to wall and release of phospholipase A, catalysing lethicin to lysolethicin which chemically irritates the wall
2. Obstruction caused gallbladder glandular secretion -> progressive distension and resulting to vascular compromise
3. Initial development is in the absence of bacterial infection, but may develop contamination with gram negatives i.e. e.coli, enterococci, enterobacter, klebsiella
4. Inflamed, enlarged and tense gall bladder + inflammatory mediators -> fever, chills, tachycardia
Acalculus cholecystits 1. Gall bladder wall inflammation and oedema -> compromised blood flow + gall bladder stasis + accumulation of micro crystals of cholesterol + mucous 2. Cystic duct obstruction |
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What are some risk factors for gall stone formation? |
Cholesterol stones (80%): Triad of... High cholesterol - Obesity, DM, age <50 - Hypercholesterolaemia - Female - Oestrogen exposure, pregnancy Low bile salts/lecithin - Terminal ileal Crohn's (decreased in bile salt resporption) - Genetic Stasis - Dehydration - Pregnancy - Rapid weight loss
Pigment stones (contains calcium bilirubinate) - Cirrhosis - Chronic haemolysis - Biliary stasis |
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How would you investigate this woman's presentation? |
Diagnostic: Abdominal US - Sonographer's Murphy's sign - Presence of gall stones - Gall bladder wall thickening >3mm - Pericholecystif fluid
If inconclusive on U/S - HIDA scan
LFT + bilirubin Amylase + lipase FBC (left shift), ESR, CRP Urinalysis to exclude renal colic and pyelonephritis ABG Group and hold/cross match
ECG |
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What are possible complications in acute cholecystitis? |
- Empyema of gall bladder: pus collection - Gall bladder mucocoele: long term cystic duct obstruction leading to accumulation of mucus - Gangrene + perforation -> peritonitis - Cholecystoenteric fisula: formation of fistula between gall bladder and duodenum -> gall stone ileus - Mirrizi syndrome: extra-luminal compression of CBD due to large stone in cystic duct - Gall bladder emphysema due to gas forming organisms i.e. clostridum |
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What are common types of stones? How do they form? |
Cholesterol stone (80%) Formation is due to an imbalance in cholesterol and it's solubalising agents i.e. bile salts & lecithin
Contents: cholesterol, calcium carbonate, phosphates, bilirubin
Typical triad: - Supersaturation of cholesterol -> nucleation of cholesterol to form a nidus - Low levels of bile salts and lecithin - Stasis
Pigment stones - Formed anywhere in the biliary tree with high concentrations of unconjugated bilirubin i.e. haemolytic anaemia - Contents: insoluable calcium bilirubinate
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Describe macroscopic appearance of acute cholecystitis |
External: large and tense, violaceous to green-black discolouration, subserosal haemorrhage, layered by fibrin, suppurative exudate
Internal: Stone with turbid and cloudy bile. Lots of fibrin, pus and haemorrhage
Wall: thickened, oedematous and hyperaemic, might be gangrenous |
