[43] Gallstones Flashcards
What are gallstones?
Gallstones are small stones that form in the gallbladder
What happens in most cases of gallstones?
They don’t cause symptoms, and can remain untreated
What can happen if a gallstone becomes trapped in a duct?
It can cause biliary colic and other complications
What do gallstones contain?
- Cholesterol
- Bile pigments
- Phospholipids
What happens if the concentrations of different constituents of gallstones vary?
Different stones can form
What is the prevalence of gallstones in those over 40 years?
8%
What are the risk factors for the gallstones becoming symptomatic?
- Smoking
- Parity
What are bile pigments?
Products of haemoglobin metabolism
Where is bile stored?
In the gallbladder
What happens to bile on gallbladder stimulation?
It passes into the duodenum
When do gallstones develop?
When bile contains too much cholesterol and not enough bile salts
What other factors are important in gallstone formation?
- How ofetn and well the gallbladder contracts
- Presence of proteins in liver and bile that either promote or inhibit cholesterol crystallisation into gallstones
How is how often and well the gallbladder contracts important in the development of gallstones?
Infrequent or incomplete emptying can cause the bile to become over-concentrated and lead to gallstone formation
How is oestrogen involved in gallstones?
It has been found to increase cholesterol levels in bile and decrease gallbladder movement, resulting in gallstone formation
What are the types of gallstones?
- Pigment stones
- Cholesterol stones
- Mixed stones
What are pigment stones?
Small, friable stones
What causes pigment stones?
Haemolysis
What are cholesterol stones?
Large, often solitary stones
What are the risk factors cholesterol stones?
- Female gender
- Age
- Obesity
What are the risk factors for developing gallstones? 🧵
- Fat
- Female
- Fertile
- Forty
- Family history
- Pregnancy and oral contraceptives
- Haemolytic anaemia
- Malabsorption, e.g. ileal resection, Crohn’s disease
Why do pregnancy and oral contraceptives increase the risk of gallstones?
Because oestrogen causes more cholesterol to be secreted into bile
How are most gallstones discovered?
Most are asymptomatic, and picked up incidentally on ultrasound scans, most commonly a trans-abdominal ultrasound
What investigations are done in gallstones?
- Liver function tests
- Ultrasound
- Consider MRCP
- Blood tests
- Urinalysis
Who should LFTs and ultrasound be offered to?
All people with suspected gallstone disease
When should MRCP be considered in gallstones?
If ultrasound didn’t detect common bile duct stones, but the bile duct is dilated or LFTs are abnormal
What should urinalysis in gallstones include if female?
Pregnancy test
Why is urinalysis done in the investigation of gallstones?
To exclude any renal or tubo-ovarian pathology
What is the first line imaging in gallstones?
Trans-abdominal ultrasound
Why is transabdominal ultrasound first line in investigation of gallstones?
Because it is one of the most sensitive modalities for visualising gallstone disease
What might trans-abdominal ultrasound show in gallstones?
- Presence of gallstones or sludge
- Gallbladder wall thickening
- Bile duct dilation
What does gallbladder wall thickening indicate?
That inflammation is likely
What does bile duct dilation indicate?
A possible stone or stricture in the distal bile ducts
What blood tests are done in the investigation of gallstones?
- FBC and CRP
- U&Es
- LFTs
- Amylase
What might FBC and CRP show in gallstones?
May show evidence of an inflammatory resposne
When might gallstones cause an inflammatory response?
In biliary pathology such as cholecystitis, cholangitis, and pancreatitis
Why should U&Es be done in gallstones?
Assess for any dehydration secondary to reduced oral fluid intake
What may be shown on LFTs in gallstones?
Biliary colic and acute cholecystitis likely to show raised ALP, indicating ductal occulsion, yet other parameters should remain within normal ranges
Why should amylase be checked in suspected gallstones?
Check for pancreatitis
When is no treatment required for gallstones?
When a person has asymptomatic gallstones found in a normal gallbladder
When should a person with asymptomatic gallstones be treated?
If they are in the common bile duct
Why should a person with asymptomatic gallstones in the common bile duct be treated?
Because that person is at high risk of developing serious complications such as cholangitis or pancreatitis
How should a person with asymptomatic gallstones in the common bile duct be managed?
Same as a person with symptomatic gallstones
What are the symptomatic presentations of gallstones?
- Biliary colic
- Acute cholecystitis
- Chronic cholecystitis
- Obstructive jaundice
- Cholangitis
- Gallstone ileus
- Pancreatitis
- Mucocoele/empyema
- Mirizzi’s syndrome
- Gallbladder necrosis
What is biliary colic?
When gallstones become symptomatic with cystic duct or common bile duct obstruction
How does biliary colic present?
Sharp RUQ pain, with or without jaundice
Where does the pain in biliary colic radiate to?
The back or right shoulder
How long does the pain last in biliary colic?
Often lasts longer than 30 minutes, up to a few housr
What other symptoms may be associated with biliary colic?
Nausea and vomiting
What might the pain follow in biliary colic?
A fatty meal and the symptom of indigestion
How should suspected biliary colic be investigated?
- FBC
- LFTs
- Lipase
- Urinalysis
- CXR
- ECG
How is biliary colic initially managed?
- Analgesia
- Lifestyle factors
What analgesia should be prescribed in biliary colic?
Typically NSAIDs and PRN opiods, along with an appropriate antiemetic
What analgesic does NICE recommend for severe pain in biliary colic?
Diclofenac 75mg IV, unless contraindicated
What can be used in severe pain caused by biliary colic when diclofenac is unsuitable or ineffective?
IM opioids, e.g. morphine
What analgesia should be offered for intermittent mild to moderate pain in biliary colic?
Paracetamol or oral NSAID
What should be done if there is no improvement with analgesia in biliary colic?
Consider possibility of cholecystitis
How are lifestyle factors involved in the management of biliary colic?
Patients should be advised about lifestyle factors that may help control symptoms and help with future surgery
What lifestyle changes should be made in the management of biliary colic?
- Low fat diet
- Weight loss
- Increasing exercise
What should be provided at discharge for biliary colic?
PRN analgesia
What is likely following the first presentation of biliary colic?
There is a high chance of symptom recurrence or development of complications
What are the complications of biliary colic?
- Cholecystitis
- Acute pancreatitis
What is done as a result of the high chance of recurrence/complications in biliary colic?
An elective cholecystectomy should be offered
How long after presentation should an elective cholecystectomy be offered?
Ideally within the first 6 weeks of presentation
What surgical technique is used for cholecystectomy?
A laproscopic route is preferred, but not always possible
What is acute cholecystitis?
Inflammation of the gallbladder that develops over hours
What does acute cholecystitis usually result from?
A stone or sludge impaction in the neck of the gallbladder
What are the symptoms of acute cholecystitis?
- Pain
- Vomiting
- Fever
- Local peritonism
- Gallbladder mass
Describe the pain in acute cholecystitis
It is continuous epigastric or RUQ pain, which may refer to the right shoulde r
What can happen in acute cholecystitis if the stone moves to the CBD?
Obstructive jaundice and cholangitis may occur
What investigations are done in acute cholecystitis?
- Examination
- FBC
- Ultrasound
- Plain AXR
What are the examination signs in acute cholecystitis?
- Murphy’s sign
- May be able to palpate a phlegmon
How is Murphy’s sign detected?
By lying two fingers over the RUQ, and asking the patient to breath in
What is a positive Murphy’s test?
Pain and arrest of inspiration as the inflamed gallbladder impinges on fingers
Must also perform test in the LUQ, as positive result requires no pain on this side
What is a phlegmon?
A RUQ mass of inflamed adherent omentum and bowel
What may the ultrasound show in acute cholecystitis?
- Thick-walled, shrunken gallbladder
- Pericholecystic fluid
- Stones
- Dilated common bile duct (>6mm)
What % of gallstones can be seen on plain AXR?
About 10%
What might a plain AXR show in acute cholecystitis?
A ‘porcelain’ gallbladder
What is a ‘porcelain’ galbladder associated with?
Risk of cancer
How should patients with acute cholecystitis be managed initially?
- Started on appropriate IV antibiotics
- Fluid resuscitation
- NG tube
- Concurrent analgesia
What antibiotics can be given in acute cholecystitis?
Co-amoxiclav, with or without metronidazole
What should be done if a patient with acute cholecystitis demonstrates evidence of sepsis?
Management should be adapted accordingly
When should a NG tube be placed in acute cholecystitis?
If the patient is vomiting and made NBM
What analgesia should be prescribed in acute cholecystitis?
Typically simple analgesics and PRN opioids, and anti-emetics
What is the definitive management for acute cholecystitis?
Laparoscopic cholecystectomy
When should a laparoscopic cholecystectomy be performed in acute cholecystitis?
Within 1 week, however ideally within 72 hours of presentation
Why are earlier cholecystectomies preferred in acute cholecystitis?
Because they are safe, and reduce overall hospital stay
When is a percutaneous cholecystectomy performed?
In patients not fit for surgery and not responding to antibiotics
What is the purpose of a percutaneous cholecystectomy?
To drain the infection
What should the patient be advised of after a percutaneous cholecystectomy?
Lifestyle changes
What will patients with chronic cholecystitis typically have a history of?
Recurrent or untreated cholecystitis
What does recurrent or untreated cholecystitis lead to?
Chronic inflammation of the gallbladder wall
What are the symptoms of chronic cholecystitis?
May be asymptomatic, or symptoms may include;
- Vague abdominal discomfort
- Distention
- Nausea
- Flatulence
- Fat intolerance
What are the differential diagnoses for chronic cholecystitis?
- Hiatus hernia
- IBS
- Peptic ulcer
- Chronic pancreatitis
- Tumour
How is chronic cholecystitis investigated?
- Ultrasound
- MRCP
What is the purpose of ultrasound in the investigation of chronic cholecystitis?
To image stones and assess CBD diameter
What is the purpose of MRCP in chronic cholecystitis?
To image CBD stones
How is chronic cholecystitis managed?
Cholecystectomy
How is chronic cholecystitis managed if US shows dilated CBD with stones?
ERCP and sphincterectomy before surgery
What are the complications of chronic cholecystitis?
It conveys an increased risk of gallbladder carcinoma and biliary-enteric fistula
What is gallbladder empyema?
When the gallbladder is infected and an abscess forms within it
How do patients with gallbladder empyma typically present?
Patients are typically septic, and present with a similar-type picture to acute cholecystitis
What is gallbladder empyema associated with?
Significant morbidity and mortality
How is gallbladder empyema diagnosed?
US scan or CT scan
How is gallbladder empyema treated?
Laparoscopic cholecystectomy
What may be required intra-operatively in gallbladder empyema if there is a tense gallbladder?
Intra-operative drainage
How does the rate of conversion to open cholecystectomy in gallbladder empyema compare to uncomplicated acute cholecystitis?
It is higher
How can gallbladder empyema be managed if the patient is suitable for surgery?
Percutaneous cholecystomy
What can inflammation of the gallbladder, typically if recurrent or silent, cause?
A fistula to form between the gallbladder wall and the duodenum
What does a fistula between the gallbladder and duodenum allow?
Gallstones to pass into the small bowel
What can gallstones passing into the small bowel via a fistula cause?
Bowel obstruction
Give two conditions whereby a fistula leads to a gallstone causing bowel obstruction
- Bouveret’s syndrome
- Gallstone ileus
What happens in Bouveret’s syndrome?
When a stone impacts to cause duodenal obstruction
What happens in a gallstone ileus?
The stone impacts to cause obstruction at the terminal ileum (the narrowest part of the adult bowel)
