Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Aims of Session • To revise relevant biliary anatomy • To understand the role of the gallbladder • To appreciate how gallstone disease can present • To understand how complications of gallstones can arise and how these are treated • To explore gallstone disease through a variety of patient case based discussions Contents 1. Biliary anatomy 2. The role of the gallbladder 3. Aetiology and risk factors for gallstones 4. Diagnosing gallstone disease 5. Managing gallstone disease 6. Complications of gallstones and patient casesBiliary Anatomy The Role of the Gallbladder • Storage and concentration of bile from the liver • Squeezes bile into the duodenum to help break down and absorb fats • Cholecystokinin • Non-essential organ Definitions and Epidemiology • Cholelithiasis – gallstones within the gallbladder • Choledocholithiasis – gallstones within the bile ducts What’s the prevalence of gallstones? 10-15% of adults in US + What are gallstones made of? Europe • Cholesterol 80% are asymptomatic • Small crystals + hypomotility = stone 50% chance of further growth biliary attack 3% chance of complications Risk Factors for Gallstone Disease Strong Risk Factors Increasing age Female sex Obesity Diabetes Metabolic syndrome Family history Gene Mutations Pregnancy Rapid weight loss Non-alcoholic liver disease Total Parenteral Nutrition Medications Disease of terminal ileum/resection Haemoglobinopathy Hispanic and Native-American ethnicity Aetiology and Pathophysiology Pathophysiology • Cholesterol stones • Bile saturation with cholesterol • Symptoms and complications • Gallbladder hypomotility result from obstruction: • Accelerated nucleation • Biliary colic • Black pigmented stones • Cholecystitis • Polymerised calcium • Mirizzi syndrome bilirubinate • Acute cholangitis • Chronic haemolytic anaemia, • Acute pancreatitis cystic fibrosis, ileal disease • Cholecystoenteric fistula • Duodenal obstruction (Bouveret • Brown pigmented stones syndrome) • Stasis and infection • Gallstone ileus History and Examination • Biliary pain: • Identify risk factors • RUQ/Epigastric origin • Other non-specific features • Episodic you may find: • Radiation to right shoulder/back • Bloating, flatulence, dyspepsia • Lasts from 15 minutes – several hours • Onset ~1 hour after eating RUQ/Epigastric tenderness common in symptomatic • Associated nausea +/- vomiting gallstone disease Presence of fever or positive Presence of pain > 8 hours, fever and abdominal Murphy’s sign think acute tenderness suggests acute cholecystitis cholecystitis Investigations 1) • Laboratory testing: • Liver function tests (usually normal with simple biliary colic) • Obstructing choledocholithiasis can cause rises in ALP and GGT (ALT to a lesser extent) • Trends more helpful than one off readings • Full blood count • WCC elevated in acute cholecystitis, cholangitis, pancreatitis • Amylase (>3 times upper limit of normal in acute pancreatitis) • Initial imaging • Abdominal ultrasound (with patient fasted) Investigations 2) • Further imaging • and/or LFTs (MRI safety checklist)f choledocholithiasis from the USS • Endoscopic ultrasound can be used if MRCP is contraindicated • Abdominal CT scan if conditions other than gallstone disease are suspectedOther Differential Diagnoses – Biliary pain Peptic ulcer disease Gallbladder cancer Acalculous cholecystitis Gallbladder polyps Non-biliary acute pancreatitis Sphincter of Oddi dysfunction Management of Gallstone Disease • Symptomatic gallstones (uncomplicated) • Pharmacological • NSAID (Diclofenac) • Antispasmodic (Buscopan) • Paracetamol (WHO pain ladder) • Surgical • Laparoscopic cholecystectomy • Asymptomatic gallstones • Do not treat unless • High risk of developing GB carcinoma • High risk of complications i.e. sickle cell disease Complications of Gallstone Disease Common bile duct stones (asymptomatic) • with bile duct clearancecystectomy Acute cholecystitis • Resuscitate, triple therapy antibiotics and laparoscopic cholecystectomy (hot or cold) Acute cholangitis • and decompression of CBD (ERCP)ibiotics Acute gallstone pancreatitis • Supportive treatment with laparoscopic cholecystectomy when recovered Patient Case 1) You are the FY1 in the surgical observation unit looking after a 55 year old lady who presents with sudden onset RUQ pain. She is sweaty and clearly uncomfortable at the bedside. Her initial observations are: HR 100, BP 115sys, RR 16, O2 sats 97% in air, temperature 37. How will you proceed? Patient Case 1) You ato her right shoulder, comes and goes, never had this pain before, currently 8/10, feelsing nauseated. old lady who presents with PMH – HTN, obesity, previous C-section She is sweaty and clearly uncomfortMeds – Ramipril, NKDA Family history – Nil Her initiSocial – works in admin role, independent, drinks occasionally, smokes 5/day air, tICE – don’t know what is causing this, ‘maybe it was the fish and chips I had for tea?’ How will you examine the patient? What are you looking for? Patient Case 1) You are the FY1 in the surgical observation unit looking after a 55 year old lady who presents wi h sudden onset RUQ pain.right side of abdomen. No jaundice, looks pale. She is sweaAbdomen soft with tenderness in RUQ, non distended. Her initial observations are: HR 100, BP 115sys, RR 16, O2 sats 97% in air, temperature 37. How would you like to investigate the patient what tests will you order? Patient Case 1) You are the FY1 in the surLFTs are normalon unit looking after a 55 year old lady who presentWCC and CRP ormal limitspain. She is sweaty and clearly un omfortable at the bedside.rmal gallbladder, no biliary dilatation, pancreas obscured by overlying Her initial observations are: HR 100, BP 115sys, RR 16, O2 sats 97% in air, temperature 37. What is the diagnosis? How will you treat the patient? Patient Case 1) old lady who presents with sudden onset RUQ pain.looking after a 55 year She is sweaty and clearly uncomfortable at the bedside. Her initial observations are: HR 100, BP 115sys, RR 16, O2 sats 97% in air, temperature 37. Patient agreeable to cholecystectomy and your registrar arranges a theatre slot. Patient’s pain settles and they are ready to be discharged home to await their surgery. Patient Case 2) • You are the FY1 working in surgical admissions overnight and the nurses call you to the bedside of an elderly man who came in earlier that day and has become acutely confused. He is 80 year old Mr J who came in initially with RUQ pain and fever. He is pleasantly confused, not orientated to time, place or person. His observations read: HR 110, BP 95sys, RR 19, O2 sats 95%, temp 37.9 • He is unable to give you a history, how will you proceed? Patient Case 2) • YThe nurse tells you that he has known gallstones and is awaiting a nurses call you to the bedside of an eld ly man who came in earl er that day and has become acutely confused. He is 80 year old Mrs. Johnstone wh came in initially with RUQ pain a d fever.she offers to He is pleasantly confused, not orientated to time, place or person. His observations read: HR 110, BP 95sys, RR 19, O2 sats 95%, temp 37.9 • What are you looking for on clinical examination? Patient Case 2) • YThe pati nt is jaundiced and itching his arms and legs, he is conscious b t remains confused. H feels hot and sweaty andn earlier bethat day and has b come acutely confus d. He is 80 year old Mr Johnstone who c me in initially with RUQ pa n and fever. He is pleasantly confused, not orientated to time, place or person. His observations read: HR 110, BP 95sys, RR 19, O2 sats 95%, temp 37.9 • From his investigations on admission what would you like to see? Patient Case 2) • You are the FY1 working in surgical admissions overnight and the Wcc is nurses call you to the bedside of an elderly man who came in earlier His CXR and ECG were in keeping with history of emphysema and previous that day and has inferior MI with nil new acute find ngs.ld Mr Johnstone who came inotherwise normal gallbladder.fever.lstones in an He is pleasantly confused, not orientated to time, place or person. His observations read: HR 110, BP 95sys, RR 19, O2 sats 95%, temp 37.9 • You ask the nurse to take some blood cultures. What do you think is going on? Patient Case 2) •You aare concerned that this patient may have acute cholangitise wnurses call you to the bedside of an elderly man who came in earlier but there is al o confusion and hypotension. Who’s pentad isMr Johnstone who came in initially with RUQ pain and fever. He is pleasantly confused, not orientated to time, place or person. His observations read: HR 110, BP 95sys, RR 19, O2 sats 95%, temp 37.9 • You review the patient’s drug chart to find that it’s partially filled in with his regular medications but nothing else – what would you like to prescribe? What scan he is booked for tomorrow? Patient Case 2) • Mr J became acutely unwell during admissi n equiring initiation ofses call you to the edside of an elderly man who came in earlier that day and has becoanalgesia and cautious IVF regimen was prescribed.e who came in initially with RUQ pain and fever. HHe is pleasantly confused, not orientated o time, place or person. His observations read: HR 110, BP 95sys, RR 19, O2 sats 95%, temp 37.9 • His CT scan confirms our suspicions of acute cholangitis and following resuscitation and antibiotics he starts to settle. Your registrar arranges for him to be first on the list for ERCP the following morning. Patient Case 3) • You are assisting your FY2 seeing a sick patient in A&E who has been referred to the general surgeons. They are 64 year old Mrs D who developed sudden onset epigastric pain and vomiting 10 hours ago. She looks unwell from the end of the bed and you help your FY2 by getting some IV access for her. Her initial observations show: HR 124, BP 90sys, RR 22, O2 sats 90%, T emperature 38 • How should this patient be assessed? What are the questions we would like to ask in a focused surgical history? Patient Case 3) • You are assisting your FY2 seeing a ck patient in A&E who has beenake off som referred to the general surgeons. They are 64 year old Mrs D whoinary catheter. developOnce A-E assessment is complete your FY2 begins to reassess. She lmedical history, Last meal and Events leading up to the presentation)st getting some IV access for her. Her initial observations show: HR 124, BP 90sys, RR 22, O2 sats 90%, Temperature 38 • What bloods should be taken here and what fluids will you prescribe? Patient Case 3) You prescribe a stat bag of Plasmolyte 500ml and take off the following referre to the general surgeons. They are 64 year old Mrs D who . Tdeveloped sudden onset epigastric pain and vomiting 10 hours ago., She looks unwell from the nd of th bed and you he p your FY2 by getting some IV access for her. and lactate of 4.5, glucose 10. Her initial observations show: HR 124, BP 90sys, RR 22, O2 sats 90%, Temperature 38 • What is the likely diagnosis for this patient? What initial investigations will you help your FY2 to order? Patient Case 3) •referred to the general surgeons. They are 64 year old Mrs D who been developed sudden onset p gastric pain and vomiting 10 hours ago. following analgesia and go d fluid resuscitation. They helpFY2 by getyou t prescribe ongoing fluids for what is supportive Her initial obsetherapy for acute pancreatitis., RR 22, O2 sats 90%, Temperature 38 • What is the likely cause of this patient’s pancreatitis and what else do they need to be offered once they have recovered from this acute episode? Patient Case 4) •and are helping to look after 79 year old Mr G. He has been on the ward for some time recovering from pneumonia and AKI. The team notice he has had some weight loss and he has become quite anaemic. The concerned MOE registrar orders a CTCAP looking for underlying malignancy. The CT shows that there is a large mass in the sigmoid colon with no evidence of locally invasive disease. The report also finds that there is biliary dilatation and an obstructing stone in the distal common bile duct. • He is referred to the colorectal surgeons and you think about the management of asymptomatic choledocholithiasis. Patient Case 4) • helping to look after 79 year old Mr G. He has been on th w rd fore somno es. You see that he has not had any LFTs taken this The teaadmission, though he is not vi ibly jaundiced.uite anaemic. The concerned MOE registrar orders a CTCAP looking for Yunderlying malignancy.dated bloods including LFTs and go The CT shows that there is a large mass in th sigmoid colon with no evidence of locally invasive disease. The report also finds that there is biliary dilatation and an obstructing stone in the distal common bile duct. • What would concern you in the examination of a patient with known choledocholithiasis? Patient Case 4) • helping to look after 79 year old Mr G. He has been o the ward f re somt nder abdomen. Whilst you are unable to palpate the The team sigmoid mass you detect no other ma ses.e is quite anaemic. The concerned MOE registrar orders a CTCAP looking for Hunderlying malig ancy.and the bilirubin level is 25 (normal). The CT sHis observations re all within nor al limits.d colon with no evidence of locally invasive disease. The report also finds that there is biliary dilatation and an obstructing stone in the distal common bile duct. • What should patients with asymptomatic choledocholithiasis be considered for? Patient Case 4) • You are working in a medicine of the elderly ward as an FY1 and are helping to look after 79 year old Mr G. He has been on the w rd for asome time recovering after a nasty pneumonia and AKI.teams. This pThe team notice he has had some weight loss and he is quitfor ranaemic. The concerned MOE registr r orders a CTCAPrative intent, it loois likely he will receive adjutive chemotherapy. It is agreed that he will undergo ERCP pre-operatively and have a finds that there is biliary dilatation and an obstructing stone in the distal common bile duct. surgery. • The patient goes on to do very well. Thank you! • Saskia.clark-stewart2@nhs.scot