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Path: Liver 6 - Gallstones + Pancreatitis (ii) (Acute cholecystitis…
Path: Liver 6 - Gallstones + Pancreatitis (ii)
Gallstones Complications
acute cholecystitis + its complications
CBD obstruction
obstructive jaundice (extrahepatic cholestasis)
ascending cholangitis - do rapid cholecystectomy as can be fatal
acute pancreatitis - do rapid cholecystectomy as can be fatal
Mirizzi syndrome -rare
GB adenocarcinoma (rare, low overall risk)
risk of any of these occurring with gallstones is approx 1% - higher if biliary colic present
Acute cholecystitis
nearly always (>90%) a/w gallstones
sustained cystic duct obstruction causing
stasis in GB
secondary infection
small % calculus (no stone) - usually occurs in ICU due to not eating
fever, nausea, vomiting, RUQ pain for days
Murphy's sign +ve (ask patient to breathe out, place hand below right costal margin @ mid-clay line, ask them to breath in - +ve if arrest of inspiration due to pain)
high WCC
characteristic US findings
no jaundice except in Mirizzi syndrome
tx
fluids
analgesia
antibiotics
cholecystectomy
complications
occur in 10-20%
empyema (chronically enlarged abscess, obstructed, ongoing active inflamm)
mucocoele (mucus cyst, chronically obstructed, sterile)
necrotising inflamm with risk of perforation (bile v toxic to peritoneum)
pericholecystic abscess or generalised biliary peritonitis (v rare, high mortality)
adhesions to duodenum +/- cholecytoduodenal fistula (! allows bigger stones to pass through + block terminal ileum - gallstone ileus - SI obstruction)
Chronic cholecystitis
histopathological finding rather than clinical entity
subclinical, asymptomatic
pathological description of findings in most removed GBs @ surgery
always a/w gallstones
no specific/reliable correlation with symptoms
GB shows chronic response to repeated cycles of obstruction/inflamm
fibrotic, shrunken, with gallstones, thickened muscle, atrophied mucosa, diverticulae
Gallstone tx
remove if symptomatic (biliary colic or complications)
if asymptomatic (incidental find): observe
case selection for surgery NB
more vague symptoms may not be reliably related to stones - risk of PCS (persisting symptoms)
cholecystectomy
open
laparoscopic
shorter stay (no big abdo wound to heal)
lower mortality (0.1 vs 0.5%)
greater risk of bile duct injury (1.5%)
medical tx (UDCA, lithotripsy) not indicated
for CBD stones
exploration @ laparoscopic cholecystectomy
or ERCP
extrahepatic bile duct obstruction
causes
stones in CBD
tumour
adenocarc of pancreas
extrahepatic bile duct adenocarc
benign stricture
post-op
PSC
mass outside CBD/CHD compressing the CBD
Mirizzi syndrome (stone in neck of GB/cystic duct)
tumour or mets in lymph nodes
Courvoisier's law
historic interest only
a palpable enlarged non-tender GB + mild painless jaundice is unlikely to be stones (carcinoma)
investigations
US shows dilated ducts above obstruction
cause may need investigating: MRCP or EUS
ERCP if tx intended after definitive dx made
tx
decompression +/- tx cause
stones: ERCP with sphincterotomy (make sphincter of Oddi bigger) +/- stone removal, CBD exploration @ surgery (laparoscopic or open)
stricture or tumour: stent (usually via ERCP)
Ascending acute cholangitis
infection in static obstructed bile
Charcot's triad
fever
jaundice
RUQ pain
add hypotension + altered mental state = Reynolds' pentad
requires urgent decompression
Hepatic abscess
biliary tract disease a/w ascending infection = commonest cause
seeding from systemic sepsis sometimes the cause
historically common cause was spread via portal vein from intra-abdo sepsis
tx = drain + antibiotics
could be an amoebic abscess