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ABDOMINAL P AIN + BILIARY PATHOLOGY CASE 13: ANNA PRITCHARD Juliet Benson Imperial College London jb319@ic.ac.uk 26/01/2025SESSION PLAN - Examples of biliary pathology - Formation of stones - Signs & symptoms of cholecystitis - Investigations - Treatment Imperial College London IMAGING- What might we see on the abdo •USStones • Distended GB • Thickened GB wall • Pericholecystic fluid • HYPERECHOIC CT Scan - Why do we use it sometimes? It can detect emphysematous cholecystitis, GB perf Imperial College LondonBILIARY COLIC- LEAST SEVERE- USUALY ARUQ pain caused by TEMPORARY obstruction of the cystic duct during post-prandial gallbladder contraction NO INFLAMMA TION - normal OBS • Fatty food triggers cholecystokinin release = increased contractions against gallstones • SEVERE CONSTANT PAIN unlike normal colic • Pressure in gallbladder rises= distension (SWELLING) • Dull RUQ pain constantly lasts for 20-30 minutes for <6 hours then GOES AWAY - stone falls back into GB • May remove gallbladder if pain is too much Imperial College London 4 26/01/2025 Character (and time course) of Pain: ‘Colicky Pain’ Imperial CMr D Spalding – Abdo Pain Tutorial – 20/01/2021Acute cholecystitis is inflammation of the gallbladder due to biliary outflow obstruction from the Blockage more permanent- gallbladder distension • Severe, CONSTANT epigastric/ RUQ pain >8 HOURS • Nausea and vomiting • NO fever and tachycardia(high HR) • Raised WBC and CRP , sometime ALP slightly raised • Normal LFT/bilirubin • not much systemic upset ImperialEdit this text via6Insert > Header and Foot26/01/2025 RISK FACTORS FOR DEVELOPING GALLSTONES “FAT, FEMALE, FORTIES, FOETUS” OBESITY TYPE 2 DIABETES + OCP + OVER THE AGE OF 40 Imperial CEdit this text via Insert 7 Header and Footer 26/01/2025 ACUTE / ASCENDING CHOLANGITIS - MOST SEVERE Inflammation AND infection of the biliary tree due to the obstruction of bile flow • Stone MIGRATES from cystic duct to common bile duct = INFLAMMATION • Much worse systematically- infection, tachycardia , low B, fever- sepsis-like picture • Raised WBC, CRP , ALP, BILIRUBIN ImperiEdit this text vi8 Insert > Header an26/01/2025 How can we DIFFERENTIA TE? Secretions NO jaundice - connection between from liver can’t liver and gall bladder still intact go into small intestine Imperial -Note of caution: jaundice is present in 10% ofQUESTION Imperial College London BILE - Made mainly of water BILE COMPOSITION: • water (98%) (97%) - Some pigments present • bile salts, (0.7%) (eg: calcium bilirubinate) • cholesterol (0.5%) - Bile acids aggregate to form micelles which • bilirubin (0.2%) • normal electrolytes emulsify fats 80-90% + Mixed Imperial Collestonesdon stones PIGMENT STONES Black stones: • Generally due to overproduction of bilirubin • Think: haemolytic anaemia Brown stones • Bacterial and helminthic deconjugation of bilirubin glucuronides Imperial Edit this text via In12rt > Header and Footer 26/01/2025FACTORS FOR CHOLESTEROL STONE FORMATION 1.SUPERSATURATION- Amount of cholesterol exceeds cholesterol saturation index 2. NUCLEATION- Kinetic factors (proteins promoting crystallisation) 3. HYPOMOTILITY- Healthy people can flush out supersaturated bile Imperial College Londonight lossImperial College London Edit this text via Insert > Header and Footer 14 26/01/2025 Basic Investigations FBC – WHITE CELL COUNT , NEUTORPHILS -Inflammatory markers (eg: CRP) -U&Es -LFTs – AST , ALP , BILIRBIN -Amylase & lipase -Blood cultures ± bile cultures (how?) -Beta-HCG! Imperial College LondonTreatment -Analgesia and fluids -Consider Abx -Early/delayed cholecystectomy (these days virtually all laparoscopic) -Percutaneous cholecystostomy (if patient deemed unfit for surgery) Imperial College London COMPLICA TIONS - Mirizzi Syndrome - Pancreatitis - Cholecystoenteric fistula + gallstone ileus/Bouveret syndrome - Suppurative cholecystitis (gallbladder empyema) - Emphysematous cholecystitis - GB perforation - Gallbladder cancer/cholangiocarcinoma Imperial College LondonPancreatitis Imperial College LondonCholecystoenteric fistula -> gallstone ileus Imperial College LondonRadiation of Pain -Appendicitis: sharp pain starts centrally and gradually radiates to RIF -Pancreatitis and abdominal aorta pathology (eg: AAA) “ epigastric pain radiating to the back” -Pain arising from kidneys radiates from flanks to loin ” RUQ pain radiating to shoulders” What sign is this??? Imperial College LondonLaparoscopic cholecystectomy - Divide cystic duct and cystic artery - Keyhole surgery - Remove GB COMPLICATIONS - Infection - Bleeding - DVT - Bowel injury - Biliary injury - Post cholecystectomy Imperial College Londons Cosyndromend WarwickshireWhat do you need to gain valid consent Laparoscopic cholecystectomy= ELECTIVE procedure ( not an emergency!) Must obtain WRTTEN consent Imperial College Londonretain, weigh up pros+ cons, communicate thoughtsSites of Pain and common scars Imperial College London Mr D Spalding – Abdo Pain Tutorial – 20/01/2021WHO CAN ASK FOR CONSENT? A- Someone who knows how to perform the procedure B- Medical student C- Anyone that can answer questions that the patient may have D- Anaesthetist E- Consultant neurosurgeon F- General surgery registrar G- Surgical FY2 doctor H- Anyone who knows what the procedure is about Imperial College LondonIn which of these disorders would MURPHY’S SIGN be present? - BILIARY COLIC - CHOLECYSTITIS - ASCENDING CHOLANGITIS MURPHY’S SIGN- if you put hand on RUQ and ask patient to inhale, inhalation pushes down diaphragm and GALLBLADDER, but GB is INFLAMED AND PAINFUL, patient will just STOP BREATHING at some point Imperial CoEdit this text via Insert >25eader and Footer 26/01/2025 THANK YOU Juliet Benson – jb319@ic.ac.uk