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Gallstone Ileus and Gallbladder Carcinoma
Gallstone enters and obstructs the small intestine
Due to cholecystitis with fistula formation between the gallbladder and small intestine
As the stone advances it may cause intermittent "tumbling" obstruction with diffuse abdominal pain and vomiting
Vomiting, pneumobilia (air in the biliary tree), hyperactive bowel sounds, and dilated loops of bowels
Until finally lodging in the ileum, the narrowest section of the bowels, several days later
Diagnosis: abdominal CT scan which reveals gallbladder wall thickening, pneumobilia, and an obstructing stone
Treatment is surgical and involves removal of the stone and either simultaneous or delayed cholecystectomy
In addition to experiencing colicky pain and vomiting, patients may report distension and inability to pass flatus or stool
May show signs of hypovolemia (eg, hypotension, tachycardia)
Adenocarcinoma arising from the glandular epithelium that lines the gallbladder
Risk factors: gallstones and especially when also combined with porcelain gallbladder
Presents as cholecystitis in elderly women
U. Right Upper Quadrant pain, thickened gallbladder, patchy uniform calcification
Waxing and waning right upper quadrant pain
Due to gallbladder contracting against a stone lodged in the cystic duct
Relieved with stone passing
Common bile duct obstruction may result in acute pancreatitis or obstructive jaundice
Associated with nausea/vomiting
Neurohormonal activation (eg, by CCK after a fatty meal) triggers contraction of gallbladder
Labs are normal, ultrasound shows cholelithiasis
Features that distinguish biliary colic from cholecystitis are pain resolution within 4-6 hours and absence of abdominal tenderness, fever, and leukocytosis
Chronic inflammation of the gallbladder
Due to chronic chemical irritation from longstanding cholelithiasis with or without superimposed bouts of acute cholecystitis
Characterized by herniation of gallbladder mucosa into the muscular wall (Rokitansky-Aschoff sinus)
Presents with vague right upper quadrant pain, especially after eating
Porecelain gallbladder is a late complication
Shrunken, hard gallbladder due to chronic inflammation, fibrosis and dystrophic calcification
Increased risk of carcinoma
Treatment: cholecystectomy, especially if porcelain gallbladder is present
Plain x-rays can show a rimlike calcification, CT scan typically reveals a calcified rim in the gallbladder wall with a central bile-filled dark area
Cholecystectomy considered for porcelain gallblad der, particularly if symptomatic or have incomplete mural calcification
Prophylactic cholecystectomy if they have symptoms of gallbladder disease (eg, biliary colic) or if punctate calcifications are present
Curvilinear gallbladder calcifications minimally increase cancer risk and generally do not require intervent ion
Bacterial infection, tissue necrosis - causes early release from bone marrow (left shift)
Left shift - decreased Fc receptors (CD16)
Increased neutrophil precursors, such as band cells and metamyelocytes
High cortisol states - impairs adhesion of a marginated pool of neutrophils in pulmonary vasculature
Chronic inflammatory (autoimmune and infectious), malignancy
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