this section in the GI lecture series went over the diagnosis of the various gall bladder pathologies; mainly biliary obstruction, acute cholelithiasis, and choledocholithiasis. gallstones are most commonly formed in older patients from high cholesterol levels, which causes the bile salts to precipitate out of solution. there biliary obstruction can cause pain that follows meals or wakes patients at night, plateaus for 3-4 hours, then subsides. it is a RUQ pain that often radiates around to the lower right scapula, and a positive Murphy's sign is helpful to diagnose gallbladder inflammation. imaging of the gallbladder via ultrasonography will show wall thickening and distention of the gall bladder, which should be monitored in patients periodically to determine efficacy of treatment. acute cholelithiasis presents as an unrelenting pain, mainly from the inflammation of the GB itself, as opposed to simply obstruction as in biliary obstruction. it can also be differentiated diagnostically by a low grade fever and a high WBC count. finally, choledocholithiasis is an obstruction of the common bile duct which may lead to cholangitis, obstructive jaundice, acute pancreatitis, and biliary pain.
questions
cholelithiasis...
1. what percentage of americans have gallstones?
2. what are gallstones formed by?
3. what are black gallstones associated with?
4. what are brown gallstones associated with?
5. what is the composition of cholesterol gallstones?
6. what is the cause of cholesterol gallstones?
7. how is the apoe4 gene related to gallstones?
8. what is the most common age of patients with gallstones?
9. gallstones are most prevalent in which demographic populations?
10. what type of diet is associated with formation of gallstones?
11. what are some hormonal factors associated with gallstones?
12. why does low progesterone facilitate gallstone formation?
13. what are some other risk factors associated with cholesterol gallstone formation?
14. what are some risk factors for pigment stones?
15. what are the "five F" predisposing factors for gallstones?
cholethiasis diagnosis...
16. what are three common clinical presentations for patients with gallstones?
17. how do the majority of patients with gallstones present?
18. describe the quality of the pain in a "biliary colic" presentation.
19. complicated biliary stones are similar to colic presentation, but with...
20. what percentage of people with mild gallstone symptoms have complications after 20 years?
21. describe the quality of pain in people with acute cholecystitis.
22. what is the difference in the source of pain with biliary colic vs. acute cholecystitis?
23. what is the location and radiation pattern of the pain from biliary colic or acute cholecystitis?
24. what are some PE findings of patients with biliary colic or acute cholecystitis?
25. what is the imaging technique of choice for gallstones?
26. what the criteria for diagnosing gallstones via ultrasonography?
27. what is the "HIDA scan"?
28. what are some possible differential diagnoses for gallstones?
29. what is the naturopathic treatment strategy for gallstones?
30. what is the "porcelain gallbladder" finding?
31. what is a complication of choledocholithiasis?
acute cholecystitis revisited...
32. what is acute acalculous cholecystitis? what percentage of childhood gallstones are of this type?
33. what are the triggers of acute cholecystitis?
34. what are the signs and symptoms of acute cholecystitis?
35. what are the PE findings for acute cholecystitis?
36. what are the lab findings for acute cholecystitis?
37. what are the imaging techniques used to diagnose acute cholecystitis?
choledocholithiasis...
38. what is choledocholithiasis?
39. what percentage of patients with choledocholithiasis are asymptomatic?
40. what are the 4 possible outcomes of choledocholithiasis?
41. what is a severe complication of choledocholithiasis and what is the prognosis?
answers
1. 10-20%.
2. cholesterol, bilirubin, calcium salts, proteins.
3. chronic hemolytic disorders, younger patients.
4. impaction of biliary tract.
5. 70-90% cholesterol, lecithin, bile salts.
6. inflammation of liver leads to high lipid levels, leads to high cholesterol content in the bile, leads to supersaturation of bile in cholesterol, leads to precipitation of bile salts.
7. a gene that is related to higher lipid levels which will lead to cholesterol gall stones as described above.
8. very uncommon in children, more in older people.
9. western caucasians, hispanic, native american, pima indian.
10. standard american diet or rapid weight loss diet programs.
11. high estrogen levels compared to progesterone, pregnancy, birth control pills.
12. by inhibiting gallbladder motility, leading to biliary stasis.
13. parenteral nutrition, cystic fibrosis, pancreatic insufficiency, vagotomy.
14. chronic hemolysis
alcoholic cirrhosis
increased age
infection
periampullary diverticulitis
15. fair, fat, forty, fertile female.
16. asymptomatic, biliary colic, "complicated".
17. 60-70% present asympatically.
18. colicky pain in the RUQ following meals. pain gradually increases over 15-30 minutes and lasts for several hours.
19. fever, increased WBC's.
20. 50%.
21. unrelenting.
22. BC: pain from obstruction of cystic ducts. AC: pain from inflammation of GB.
23. well localized RUQ, radiates around to right scapula.
24. RUQ tenderness/pain
abdominal guarding
tachycardia
fever (if acute cholecystitis)
positive Murphy's (if acute cholecystitis)
hypertension
25. ultrasonography.
26. gallbladder distention and wall hypertrophy, pericholecystic fluid, sonographic Murphy's sign.
27. biliary scintigraphy.
28. appendicitis
diverticular disease
IBS
pancreatitis
hepatitis
esophageal spasm
GERD
peptic ulcer
pneumonia
29. follow up and do reimaging to ensure thinning of GB walls. lifestyle modification.
30. calcification of GB walls.
31. pancreatic insufficiency.
32. inflammation of GB without gallstones. 50% of childhood cases.
33. fasting, stress, trauma, weight loss dieting.
34. RUQ pain radiating to lower R scapula
rebound tenderness
anorexia
nausea / vomiting
splinting of respiration
low grade fever
mild jaundice
35. positive Murphy's sign and palpable GB.
36. elevated WBC
shift to the left
mild elevation of transaminases
increased bilirubin and alk phos
increased amylase.
37. ultrasound, biliary scintigraphy.
38. obstruction of the common bile duct.
39. 10%.
40. cholangitis, obstructive jaundice, acute pancreatitis, biliary pain.
41. suppurative cholangitis, 50% mortality due to sepsis.
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