Makindo Medical Notes"One small step for man, one large step for Makindo" |
|
---|---|
Download all this content in the Apps now Android App and Apple iPhone/Pad App | |
MEDICAL DISCLAIMER: The contents are under continuing development and improvements and despite all efforts may contain errors of omission or fact. This is not to be used for the assessment, diagnosis, or management of patients. It should not be regarded as medical advice by healthcare workers or laypeople. It is for educational purposes only. Please adhere to your local protocols. Use the BNF for drug information. If you are unwell please seek urgent healthcare advice. If you do not accept this then please do not use the website. Makindo Ltd. |
Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis
Mortality from acute cholecystitis is estimated to be less than 10%. Acute acalculous cholecystitis is a life-threatening condition with a mortality rate of up to 50% and has its own topic.
Initial Management Summary |
---|
|
Type | Notes | Incidence |
---|---|---|
Mixed stones | Multiple and faceted stones of cholesterol, calcium bilirubinate, phosphate and protein primarily due to the precipitation of cholesterol | 70% |
Cholesterol stones | Usually solitary stones. May be seen with raised cholesterol, diabetes, pregnancy and OCP. Can result in a "Strawberry gallbladder" with submucous cholesterol collections. Reduced bile salts and phospholipids increase stone formation | 20% |
Pigment stones | Small dark stones. Multiple. Fragile stones. Haemolytic anaemias | 5% |
Brown stones | biliary infections with Clonorchis sinensis | Very rare in UK |
Calot's triangle or the Cystohepatic triangle is the region in the liver bed bounded by the cystic artery, cystic duct and common hepatic duct, all of which must be identified and protected during laparoscopic cholecystectomy.
Type | Clinical | Management |
---|---|---|
Asymptomatic | Vast majority | Only 7% need gallstone related surgery within 5 years. Managed conservatively usually. Symptomatic disease does require surgery |
Biliary colic | A stone in the cystic duct or even the CBD can cause right upper quadrant pain "Biliary colic". However biliary colic is a misnomer as the pain tends to be fixed and last 1-2 hours. It is not colicky. Can radiate to the scapula. Fatty intake can precipitate symptoms. Nausea and bloating and dyspepsia. Can be severe. Relieved when the stone falls back into the GB or be passed | Avoid fatty meals. If severe the admit, IV fluids, analgesia. Elective cholecystectomy. |
Acute calculous cholecystitis | RUQ pain fever, toxaemia, tachycardia, raised WCC due to obstruction of the cystic duct, increased gallbladder pressure and vascular compromise. Positive Murphy's sign - a hand placed in RUQ and patient asked to take a deep breath which stops suddenly when the hand comes into contact with the inflamed gallbladder. As mass may be palpable | Admit, IV fluids, IV antibiotics, analgesia, Laparoscopic Cholecystectomy |
Ascending cholangitis | Charcot's triad: Jaundice + RUQ pain + rigors/fever. Suspect in anyone with biliary stones who develops septicaemia. Caused by infection with E. coli, Bacteroides, Klebsiella, Clostridium. ERCP is the gold standard and procedure of choice. | Admit, IV fluids, IV antibiotics, analgesia, Decompression of the biliary system by ERCP or radiological or surgical means. Elective (Laparoscopic) Cholecystectomy then or 6 weeks post-discharge. Cholecystectomy has a high risk of further attacks which can have significant even fatal complications. |
Chronic cholecystitis | Repeated episodes of cholecystitis lead to a small thickened wall fibrosed gallbladder | Elective Cholecystectomy |
Mirizzi syndrome | An impacted stones in the cystic duct causing an inflammatory mass compressing the Common bile duct | |
Impaction in the common bile duct | Acute onset of obstructive jaundice. The acute onset and a history of biliary pain helps differentiate it from pancreatic carcinoma. Choledocholithiasis and possibly obstructive jaundice and ascending cholangitis. USS and MRCP can be diagnostic and MRCP can show if a stone has passed such that ERCP is not needed | ERCP should remove any residual non passed stones pre-surgery and then elective cholecystectomy. In some cases, CBD stones can be removed at Cholecystectomy doing an explorative study of the CBD which can be tricky and time-consuming especially so if laparoscopic |
Gallstone Pancreatitis | Due to the impact of a stone in the ampulla of Vater. Epigastric pain to back + raised amylase. See pancreatitis | ERCP with sphincterotomy. Elective Cholecystectomy is advised within 3 weeks of acute attack. |
Acute acalculous cholecystitis | pain fever raised WCC and positive Murphy but in absence of stones. Possibly due to sludge or gas. Increased gallbladder pressure and vascular compromise. Treat with antibiotics and supportive. Gangrene and perforation are more common. | Urgent cholecystectomy may be indicated. Associated with fasting, TPN, Sepsis, trauma, burns, opiates, IHD. |
Gallstone ileus | Fistula from gallbladder to duodenum allows large gallstone to pass. Obstructs duodenum or ileocaecal valve. AXR - free air in biliary tree. | CT is diagnostic. Resuscitate and laparotomy. Gallstone milked back to healthy small intestine and then removed. Cholecystectomy |
Empyema of Gallbladder | Severe Complication of cholecystitis with increased sepsis and clinical severity and can perforate to cause peritonitis | Admit, IV fluids, IV antibiotics, analgesia, Laparoscopic placement of drainage catheter. Laparoscopic cholecystectomy. Try to prevent perforation by early surgery |
Emphysema of the Gallbladder | Seen in Elderly, Diabetics or immunocompromised. Toxic and septic. Clostridium perfringens leading to gas in gallbladder and perforation of gallbladder seen with peritonitis with a very high mortality | Urgent fluid and antibiotics and resuscitation and laparotomy |