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29 Cards in this Set
- Front
- Back
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What are the 2 types of gallstones?
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Cholesterol - 80%
Pigment |
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How does gallbladder sludge form?
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During fasting, cholesterol crystals form in the supersaturated bile and combine with gall bladder stasis --> sludge (prediposes to stone formation)
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Why do cholesterol gallstones develop?
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They form when mixed micelles cannot maintain cholesterol in solution --. cholesterol cystals aggregate --> poorly soluble chopmonents from the bile ppt onto the growing crystals which sustains the formation of stones
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Why do pigment gallstones arise?
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Excess of unconjugated bilirubin
when there is enhanced RBC destruction (esp. extravascular haemolysis) --> enhanced bilirubin production --> unconjugated bilirubin leads to formation of pigment stones RF include increase in bilirubin load bilirubin becomes insoluble due to glucuronidases in bile (stasis or obstruction allowing contamination with glucuronidase containing bacteria) patient has cirrhosis (depletion of glucuronidase inhibitors in bile) haemolytic disease |
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What is the most common organism in infective cholecystitis?
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E Coli
Klebsiella Occasionally Strep Faecalis |
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Complications of cholecystitis?
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Empyema and nearby omentum, colon, and duodenum become inflammed and adherent to the gallbladder producing a phlegmon
--> high fever and hyperdynamic circulation of sepsis Gallbladder gangrene and local perforation (swinging fever) Fistula into bowel SBO |
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What investigations are useful in suspected gallstones?
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US
ERCP - not necessary in uncomplicated disease |
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Complications from a cholecystectomy
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duct injury - suspect if fever + persistent pain
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which type of gallstones will show up on x-ray i.e. are radioopaque?
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pigment stones
and some cholesterol stones cholesterol stones are radiolucent but some are radioopaque |
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RF for cholesterol stones
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imbalance of cholesterol and its solubilising agents
Increased cholesterol secretion impaired gallbladder emptying pregnancy, obesity, females, rapid weight loss (stasis) |
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Indications for cholecystectom
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Symptomatic
Asymptomatic + porcelin (calcified) gallbladder (risk of malignancy) sickle cell disease, paediatric patient, having bariatric surgery, DM, immunsuppression |
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What are the most common organisms involved in asceding cholangitis?
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E coli
Klebsiella Pseudomonas Enterococcus B. fragilis Proteus all gram -ve (from gut) |
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What is charcot's triad and what is it used for?
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RUQ pain
Fever Jaundice = ascending cholangitis |
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What is reynold's pentad?
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Charcot's triad + shock and confusion
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What are the symptoms and signs of ascending cholangitis?
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RUQ
Fever Jaundice Abdominal distension Acholic stools Dark urine |
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What might you see on US in a patient with ascending cholangitis?
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duct dilation
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How do you manage ascending cholangitis?
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Medical emergency requires
1. relief from obstruction (open or ERCP) 2. antibiotics (usually gram -ve sepsis) - amoxy/amp + gent |
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What is mirrizi's syndrome
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large gallstones in the gallbladder causing stricturing of the common hepatic duct
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Describe the pain associated with biliary colic and what is caused by?
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gallstone transiently impacted in the cystic duct with no infection
constant pain in the epigastric region typically at night or after a fatty meal |
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What is boureret's syndrome?
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gastric outlet/duodenal obstruction caused by a gallstone falling through a fistula
Features similar to bowel obstruction |
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How do you manage a gallstone falling through a fistula causing ileus?
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Remove the stone then wait for the fistula to heal spontaneously
Can do elective cholecystectomy down the track if patient continues to experience gallbladder symptoms |
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What complications can the elderly or people with DM get with cholecystits?
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Emphesematous cholecystitis
Gas forming organisms colonise the gallbaldder |
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It can sometimes be difficult to differentiate between cholecystitis and biliary colic. What are the differences?
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Cholecystitis
fever leukocyotisis more prolonged severe and constant pain cf. biliary colic that usually lasts for 2 hours |
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How do you manage cholectystitis?
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Hydrate, NBM, NG tube
Antibiotics - amoxy/ampicillin + gentamicin if accompanied by infection If biliary obstruction present need to treat anaerobes - add metronidazole |
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What are the causative organisms usually found in cholecystitis?
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gram negative - E coli, klebsiella, Enterococcus faecalis
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When is a cholecstectomy warranted with respect fo cholecystitis?
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Cholecystitis refractory to medical therapy
Complications - perforation, empyema |
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Complications of cholecystitis?
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gallbladder mucocele - long term cystic duct obstruction results in mucus accumulation in gallbladder
gangrene, perforation (abscess formation, peritonitis), Empyema of gallbladder Cholecystoenteric fistula Emphysematous cholecystitis Mirizzi's syndrome |
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What is acalculous cholecystitis?
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acute or chronic cholecystitis in the absence of stones typically due to gallbladder stasis, sludge forms in gallbladder
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RF for acalculous cholecytsitis
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DM
Immunosuppression ICU stay trauma patient TPN sepsis |
