Gallstones: Formation, Function, and Pathophysiology

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Questions and Answers

Explain how the release of cholecystokinin (CCK) contributes to the pathophysiology of conditions related to gallstones.

Cholecystokinin stimulates gallbladder contraction, which can exacerbate pain when gallstones obstruct the cystic duct or common bile duct as the gallbladder attempts to expel bile against the blockage.

A patient presents with RUQ pain, fever, and elevated white blood cell count, but has normal ALT and bilirubin levels. How does this presentation relate to the possible stages or severity of acute cholecystitis?

This patient likely has moderate acute cholecystitis. Elevated WCC and fever indicate progression beyond mild, but normal ALT/bilirubin suggest no Mirizzi syndrome.

Why is a pregnancy test included in the initial workup for a female patient presenting with suspected acute cholecystitis?

Pregnancy increases the risk of gallstones due to hormonal changes affecting bile composition and gallbladder motility. Also, pregnancy status influences treatment options and imaging modalities.

In the context of acute cholecystitis, describe the clinical significance of a positive Murphy's sign.

A positive Murphy's sign indicates inflammation of the gallbladder. Pain upon palpation of the right upper quadrant with inspiration suggests acute cholecystitis. Signup and view all the answers

Explain why a transabdominal ultrasound is typically the first-line imaging choice for suspected acute cholecystitis.

Ultrasound is non-invasive, readily available, and can effectively visualize gallstones, gallbladder wall thickening, and pericholecystic fluid, which are key indicators of acute cholecystitis. Signup and view all the answers

What are the key differences in management between moderate and severe acute cholecystitis, and why do these differences exist?

Both involve IV antibiotics and fluids, but severe cases require ICU admission due to end-organ damage. The differences exist because severe cases involve systemic compromise. Signup and view all the answers

Describe the mechanism by which a gallstone ileus occurs as a complication of cholecystitis.

Inflammation from cholecystitis leads to fistula formation between the gallbladder and small intestine. A gallstone then passes through the fistula and obstructs the small intestine, typically the terminal ileum. Signup and view all the answers

Explain the key difference between Bouveret's syndrome and gallstone ileus, in terms of the location of the gallstone obstruction.

In Bouveret's syndrome, the gallstone obstructs the proximal duodenum, causing gastric outlet obstruction, whereas in gallstone ileus, the stone impedes the terminal ileum, leading to small bowel obstruction. Signup and view all the answers

Why is pneumobilia considered a hallmark sign of gallstone ileus, and how does it develop?

Pneumobilia (air in the biliary tree) occurs because a fistula forms between the gallbladder and the small intestine, allowing air to enter the biliary system when a gallstone migrates into the small intestine. Signup and view all the answers

Describe the pathophysiology of Mirizzi syndrome and how it leads to obstructive jaundice despite the absence of a stone in the common bile duct.

A large gallstone becomes impacted in the cystic duct, compressing the adjacent common hepatic duct. This external compression causes obstructive jaundice, even without a stone directly blocking the common bile duct. Signup and view all the answers

Explain why ALT and bilirubin levels would be expected to be within normal range in uncomplicated acute cholecystitis, but may be elevated in cases of Mirizzi syndrome.

In acute cholecystitis, the blockage is typically in the cystic duct, not affecting the liver. In Mirizzi syndrome, the common hepatic duct is compressed, leading to backflow and elevated liver enzymes and bilirubin. Signup and view all the answers

Describe the likely cause and implications of a bile leak following a cholecystectomy, particularly in the context of a surgical drain.

A bile leak post-cholecystectomy suggests a slipped clip on the cystic duct remnant or iatrogenic injury to the bile duct. Bile in the drain and abnormal LFTs indicate bile leakage, likely requiring intervention. Signup and view all the answers

What is post-cholecystectomy syndrome, and why does it sometimes occur after gallbladder removal?

Post-cholecystectomy syndrome involves recurring abdominal pain and reflux symptoms months to years after cholecystectomy. It may be due to residual stones, bile duct injury, or unrelated GI issues. Signup and view all the answers

Compare and contrast acute calculous cholecystitis with acalculous cholecystitis, focusing on their respective etiologies.

Acute calculous cholecystitis is caused by gallstones obstructing the cystic duct. Acalculous cholecystitis is often due to gallbladder stasis, hypoperfusion, or infection in critically ill patients without gallstones. Signup and view all the answers

Explain why gallbladder empyema is considered a serious complication of acute cholecystitis, and outline the steps in its management.

Gallbladder empyema represents a collection of pus within the gallbladder, leading to significant morbidity and mortality. Management involves cholecystectomy or percutaneous cholecystostomy if surgery is not feasible. Signup and view all the answers

How does the pathophysiology of pigment stones differ from that of cholesterol stones?

Cholesterol stones are primarily due to excess cholesterol production. Pigment stones are due to increased bile pigments, typically seen in patients with increased Hb metabolism, as in haemolytic anaemia. Signup and view all the answers

Describe the clinical presentation of chronic cholecystitis and how it differs from acute cholecystitis.

Chronic cholecystitis presents with persistent RUQ or epigastric pain, nausea and vomiting. Acute cholecystitis, in contrast, presents with acute episodic pain, fever, and signs of inflammation. Signup and view all the answers

Identify potential long-term complications of chronic cholecystitis if left untreated, and explain the underlying mechanisms.

Long-term complications include gallbladder carcinoma and biliary-enteric fistula. Chronic inflammation can cause cellular changes leading to cancer, and fistulas form due to persistent inflammation eroding adjacent structures. Signup and view all the answers

Explain why amylase and lipase levels are checked in patients presenting with suspected acute cholecystitis.

Amylase and lipase are checked to rule out pancreatitis, as its symptoms may overlap with cholecystitis. Signup and view all the answers

Explain the significance of elevated ALP with normal ALT and bilirubin in the context of acute cholecystitis.

Elevated ALP (alkaline phosphatase) with normal ALT (alanine transaminase) and bilirubin suggests biliary obstruction, but without significant liver damage. In acute cholecystitis, this can indicate a gallstone obstructing the bile flow, but the liver itself is not yet significantly affected. Signup and view all the answers

Flashcards

Acute Cholecystitis

Inflammation of the gallbladder, commonly caused by gallstones obstructing the cystic duct.

Gallstone Formation

Supersaturation of bile, leading to the formation of cholesterol, pigment, or mixed stones.

Bile Composition

Bile salts, phospholipids, cholesterol, and bile pigments that aid in the emulsification and absorption of fats.