Gall Bladder MCQs

Clinical Manifestations Cholangitis may present as anything from a mild, self-limited episode to a fulminant, potentially life-threatening septicaemia. Patients with gallstone-induced cholangitis are most commonly older and female. The most common presentation is fever, epigastric or right upper quadrant pain,and jaundice. These classic symptoms, known as Charcot's triad , are present in about two-thirds of patients. The illness can progress rapidly with the development of shock and altered mental status, known as Reynolds' pentad (e.g., fever, jaundice, right upper quadrantpain, septic shock, and mental status changes ). However, the presentation may be atypical, with little if any fever, jaundice, or pain. Reference : Schwartz's Principles of Surgery 11 th edition, Chapter 32, Gallbladder and the Extrahepatic Biliary System, pg no: 1408

Complications of cholecystectomy Cholecystectomy affects the storage and excretion of bile acids (BAs), which can alter the metabolism of BAs and the gut microbiota.These changes can lead to metabolic disorders Hyperglycemia :Cholecystectomy can lead to hyperglycemia, or high blood glucose level Dyslipidemia :Cholecystectomy can lead to dyslipidemia, or abnormal levels of lipids and lipoprotein Non-alcoholic fatty liver disease (NAFLD) :Cholecystectomy can increase the risk of NAFLD Metabolic syndrome :Cholecystectomy can increase the risk of metabolic syndrome (MetS), even in patients without other risk factors like hypertension, diabetes, or dyslipidemia

Pathology and Staging Gallbladder cancer is generally adenocarcinoma . It is staged by the standard tumour node metastasis (TNM) staging system. Gallbladder cancer spreads via lymphatics, hematogenously, and notoriously into the peritoneal cavity or along biopsy or surgical wound tracts. Reference : Sabiston Textbook of Surgery 21 st Edition, SECTION X ABDOMEN, 55. Biliary System, Pg no: 1516.

Patients are mostly asymptomatic; symptoms if present are Early presentations: Right upper quadrant pain, nausea, vomiting Late features includes: Jaundice and anorexia, a palpable mass.

Gallbladder polyp. The only polypoid lesions that have malignant potential and are associated with a significant rate of harbouring malignancy are adenomatous polyps . The most consistent predictors of malignancy in gallbladder polyps are single polyp,size greater than 1 cm, and age older than 50 year s. Cholecystectomy is generally recommended for polyps larger than 1 cm and can safely be performed laparoscopically. Polyps smaller than 1 cm can undergo surveillance to demonstrate stability, with the exception in the setting of PSC, where the threshold for cholecystectomy should be lower in the population. Reference : Sabiston Textbook of Surgery 21 st Edition, SECTION X ABDOMEN, 55. Biliary System, Pg no: 1518

Ultrasonography Transabdominal ultrasonography (USG) is the initial imaging modality of choice as it is accurate, readily available, inexpensive and quick to perform . However, it is operator dependent and may be compromised by excessive body fat and intraluminal bowel gas. The size of the gallbladder and presence of stones or polyps can be determined. Acute calculous cholecystitis is diagnosed radiologically (sensitivity 90-95%) by thickening of the gallbladder wall (>3 mm), presence of pericholecystic fluid or direct tenderness when the probe is pushed against the gallbladder (ultrasonographic Murphy's sign). Additionally, the presence of inflammation around the gallbladder, the size of the CBD and, occasionally, the presence of stones within the extrahepatic biliary tree can be determined.

Incidence Gallbladder cancer generally occurs in the sixth and seventh decades of life and is two to three times more common in women than in men. Ethnicity plays an important role in the development of gallbladder cancer, with the highest incidence in women from India and Pakistan. Among North American populations, Native Americans and immigrants from Latin America have the highest rates. In the United States overall, gallbladder cancer is the most common cancer of the biliary tract and the fifth most common gastrointestinal cancer. Reference : Sabinston Textbook of Surgery 21 st Edition, SECTION X ABDOMEN, 55. Biliary System, Pg no: 1516