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2463807458710Investigations00Investigations15208257458711Bloods: amylase, lipase; FBC (mild ? WBC in biliary colic; ? WCC 60% sensitivity and specificity in cholecystitis); LFT (? ALP, GGT)AXR: gas in biliary tree means biliary-GI fistula; air-fluid level in emphysematous cholecystitis; localised ileus; may show calcified gallstone in RUQ (10-15% are radio-opaque); in gallstone ileus shows low small bowel obstruction and gas in biliary treeCXR: free subdiaphragmatic air if perforationUSS: Gallstones: 90-95% sensitivity, 95% specificity (difficult to see solitary stones in neck); also shows dilated CBD, thickening of gall bladder wall Choledocholithiasis: less sensitive Cholecystitis: 90% sensitivity, 80% specificity; may show gall bladder wall >4mm thick, gallstones, pericholic fluid, gas in wall in acalculus, gas in biliary tree, enlarged GB (>4cm x >8cm), sonographic Murphys; dilated CBD (>10mm)CT: less sensitive than USS for mild cholecystitis and small stonesHIDA scan: 95% sensitivity, 98% specificity; evaluates gall bladder function00Bloods: amylase, lipase; FBC (mild ? WBC in biliary colic; ? WCC 60% sensitivity and specificity in cholecystitis); LFT (? ALP, GGT)AXR: gas in biliary tree means biliary-GI fistula; air-fluid level in emphysematous cholecystitis; localised ileus; may show calcified gallstone in RUQ (10-15% are radio-opaque); in gallstone ileus shows low small bowel obstruction and gas in biliary treeCXR: free subdiaphragmatic air if perforationUSS: Gallstones: 90-95% sensitivity, 95% specificity (difficult to see solitary stones in neck); also shows dilated CBD, thickening of gall bladder wall Choledocholithiasis: less sensitive Cholecystitis: 90% sensitivity, 80% specificity; may show gall bladder wall >4mm thick, gallstones, pericholic fluid, gas in wall in acalculus, gas in biliary tree, enlarged GB (>4cm x >8cm), sonographic Murphys; dilated CBD (>10mm)CT: less sensitive than USS for mild cholecystitis and small stonesHIDA scan: 95% sensitivity, 98% specificity; evaluates gall bladder function2463806279515Assessment00Assessment15201906279515Gallstones: pain improved by curling up; radiates to R shoulder; worse on inspiration; constant pain; worse after meals and at night; RUQ tenderness during attack; maybe jaundice if stone in CBD; symptoms present for <6 hoursCholecystitis: symptoms >6 hours duration; radiates to R back; T >38°C; RUQ guarding and rigidity, rebound tenderness; jaundice in 20%; palpable gall bladder in 30%; Murphy’s sign (85-95% sensitivity, 87% specificity, LR+ 3); commonly associated with mild jaundice00Gallstones: pain improved by curling up; radiates to R shoulder; worse on inspiration; constant pain; worse after meals and at night; RUQ tenderness during attack; maybe jaundice if stone in CBD; symptoms present for <6 hoursCholecystitis: symptoms >6 hours duration; radiates to R back; T >38°C; RUQ guarding and rigidity, rebound tenderness; jaundice in 20%; palpable gall bladder in 30%; Murphy’s sign (85-95% sensitivity, 87% specificity, LR+ 3); commonly associated with mild jaundice2463805295265Cholecystitis00Cholecystitis15201905295265Causes: >90% from gallstones (? incidence when larger stones present); 10% acalculus (more common in elderly, diabetes, post-op, multi-organ failure, sepsis, post-partum, burns, major trauma, TPN, immunosuppression; usually occurs in hospitalised patients; infection of gall baldder wall with anaerobes / coliforms; >70% have underlying atherosclerosis; higher risk of complications)Bugs: 74% G-ive (eg. E coli, Klebsiella); 15% G+ive (eg. Staph, strep, enterococcus); anaerobes rare00Causes: >90% from gallstones (? incidence when larger stones present); 10% acalculus (more common in elderly, diabetes, post-op, multi-organ failure, sepsis, post-partum, burns, major trauma, TPN, immunosuppression; usually occurs in hospitalised patients; infection of gall baldder wall with anaerobes / coliforms; >70% have underlying atherosclerosis; higher risk of complications)Bugs: 74% G-ive (eg. E coli, Klebsiella); 15% G+ive (eg. Staph, strep, enterococcus); anaerobes rare2463804170045Complications00Complications15208254170045Gallstones: Cholecystitis; pancreatitis (5%); ascending cholangitis; gallstone ileus; perforation; fistula formation; hydropsCholecystitis: perforation (10%); subphrenic abscess; gallstone ileus (rare, usually in elderly after longstanding inflammation of gall bladder erodes into 3rd part of duodenum fistula gallstone lodges in terminal ileum), ascending cholangitis, pancreatitis, biliary-enteric fistula, emphystematous cholecystitis (especially if diabetes) gangrenous cholecystitis00Gallstones: Cholecystitis; pancreatitis (5%); ascending cholangitis; gallstone ileus; perforation; fistula formation; hydropsCholecystitis: perforation (10%); subphrenic abscess; gallstone ileus (rare, usually in elderly after longstanding inflammation of gall bladder erodes into 3rd part of duodenum fistula gallstone lodges in terminal ileum), ascending cholangitis, pancreatitis, biliary-enteric fistula, emphystematous cholecystitis (especially if diabetes) gangrenous cholecystitis1520190963931Gallstones: present in 10-20% people; asymptomatic in 80%; symptom rate 1-4%/year; 90% with biliary colic attack will have recurrent pain within 10 years (65% within 2 years)Choledocholithiasis: in 10% patients will gallstones; 2nd most common cause of CBD obstruction (1st is cancer)Cholecystitis: occurs in 1-3% of symptomatic stones; bacteria present in 20-50% (MCQ said 50-80%; in 20% of pancreatitis); gangrenous cholecystitis in 2-30%; obstruction of cystic duct critical in formation of diseaseAcalculus cholecystitis: >50% mortalityEmphysematous cholecystitis: 15% mortalityAscending cholangitis: present in 70%; requires urgent OT; Charcot’s triad = pain + jaundice + ?T = present in 25%00Gallstones: present in 10-20% people; asymptomatic in 80%; symptom rate 1-4%/year; 90% with biliary colic attack will have recurrent pain within 10 years (65% within 2 years)Choledocholithiasis: in 10% patients will gallstones; 2nd most common cause of CBD obstruction (1st is cancer)Cholecystitis: occurs in 1-3% of symptomatic stones; bacteria present in 20-50% (MCQ said 50-80%; in 20% of pancreatitis); gangrenous cholecystitis in 2-30%; obstruction of cystic duct critical in formation of diseaseAcalculus cholecystitis: >50% mortalityEmphysematous cholecystitis: 15% mortalityAscending cholangitis: present in 70%; requires urgent OT; Charcot’s triad = pain + jaundice + ?T = present in 25%2463803668395Risk Factors00Risk Factors2463802868295Gallstone Types00Gallstone Types246380964565Epidemiology00Epidemiology15201902868295Large (cholesterol) stones (70%): 5-25mm; small number; may calcify; impact at neck of gall bladder pain; radiolucentSmall (pigment) stones (30%): <5mm; multiple; difficult to see; may appear as sludge; cause pain by passage through sphincter of Oddi; caused by gall bladder dysmotility; radio-opaque00Large (cholesterol) stones (70%): 5-25mm; small number; may calcify; impact at neck of gall bladder pain; radiolucentSmall (pigment) stones (30%): <5mm; multiple; difficult to see; may appear as sludge; cause pain by passage through sphincter of Oddi; caused by gall bladder dysmotility; radio-opaque15201903668395Female; fat; fertile (HRT, OCP, pregnancy, post-pubertal); family history; rapid weight loss; haemolysis; ? age; TPN; genetic; cystic fibrosis; diabetes00Female; fat; fertile (HRT, OCP, pregnancy, post-pubertal); family history; rapid weight loss; haemolysis; ? age; TPN; genetic; cystic fibrosis; diabetes246380330200Biliary Disease00Biliary Disease329565317500Management00Management1571625330200Biliary colic: analgesia ERCP if: dilated CBD stone; risk factors for complication (eg. Cirrhosis, portal HTN, sickle cell disease) Admit if: pain returns after initial pain relief; features of cholecystitis / cholangitis Discharge criteria: resolution of pain; no fever; no upper abdominal tenderness when pain free; no features of biliary obstruction; PO intake; pain not returned after eatingCholecystitis: NBM; IV fluids; IV antibiotics (1g ampicillin QDS + gentamicin 4-6mg/kg OD + metronidazole (if gallstones); but one MCQ said recommended treatment for cholecystitis is ampicillin + gentamicin only; can use ceftriaxone / cefotaxime alone if penicillin allergy Urgent cholecystectomy if: perforation, gallstone ileus, empyema, acalculus cholecystitisGallstone ileus: IV antibiotics; IV fluids; decompression of obstruction; early cholecystetomy and repair of fistula00Biliary colic: analgesia ERCP if: dilated CBD stone; risk factors for complication (eg. Cirrhosis, portal HTN, sickle cell disease) Admit if: pain returns after initial pain relief; features of cholecystitis / cholangitis Discharge criteria: resolution of pain; no fever; no upper abdominal tenderness when pain free; no features of biliary obstruction; PO intake; pain not returned after eatingCholecystitis: NBM; IV fluids; IV antibiotics (1g ampicillin QDS + gentamicin 4-6mg/kg OD + metronidazole (if gallstones); but one MCQ said recommended treatment for cholecystitis is ampicillin + gentamicin only; can use ceftriaxone / cefotaxime alone if penicillin allergy Urgent cholecystectomy if: perforation, gallstone ileus, empyema, acalculus cholecystitisGallstone ileus: IV antibiotics; IV fluids; decompression of obstruction; early cholecystetomy and repair of fistula ................
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