biliary colic Flashcards
def of gallstones
stone formation in the gallbladder
def of biliary colic n
severe abdominal pain from obstruction of the cystic duct or CBD, most commonly by a gallstone
def of choledocolithiasis
presence of gallstones in the CBD
aetiology of gallstones
Any condition associated with haemolysis eg sickle cell disease can cause pigment stone formation
mixed stones
- contain cholesterol, calcium bilirubinate, phosphate and protein (80%)
- due to imbalance between bile salts, phospholipids and cholesterol (supersaturation), nucleation factors and gall bladder motility
pure cholesterol stones 10%
pigment stones
- 10%
- black stones made of calcium bilirubinate - raised bilirubin secondary to haemolytic disorders, cirrhosis
- brown stones due to bile duct infestation by liver fluke Clonorchis sinensis.
RF for mixed and cholesterol stones
increased age
female
obestity
DM
parenteral nutrition
drugs - oral contraceptive pill (OCP), octreotide
FH
ethnicity - pima indians
interruption of enterohepatic recirculation of bile salts eg Crohn’s
terminal ileal resection
RF for pigment stones
haemolytic disorders eg sickle cell, thalassaemia, hereditary spherocytosis
residence in far east where liver flukes are common
saint’s triad - association of gallstones, hiatus hernia and diverticulitis
RF for stones becoming symptomatic
smoking and parity
biliary colic
impaction of a gallstone in the neck of the gallbladder
Often triggered after a (fatty) meal
typically lasts < 6 hours with spontaneous resolution.
pathology of biliary colic
colic is formed by impaction of gallstone in the cystic duct
resolves when stone falls back into the gallbladder or stone remains impacted = inflammation and mucosal oedema of 3 histological grades
- acute cholecystitis
- acute suppurative cholecystitis
- acute gangrenous cholecystitis
In chronic cholecystitis the pathological changes vary from microscopic evidence of chronic inflammation with the mucosa penetrating the muscle layer as Rokitansky-Aschoff sinuses to a shrunken fibrosed gallbladder with transmural fibrosis.
Rarely, dystrophic calcification occurs resulting in a ‘porcelain gall-bladder’, with increased risk of malignant transformation.
epi of gallstones
v common - 10%
3x more females in younger population, equal sex ratio after 65yrs
about 50000 cholecystectomies are performed every yr
90% are asymptomatic
sx of gallstones
90% asymptomatic - so found incidentally
biliary colic
acute cholecystitis
chronic cholecystitis
ascending cholangitis
obstructive jaundice
acute pancreatitis
cholangitis
gallstone ileus
mucocoele/empyema - obstructed bile duct fills with mucus secreted by gall bladder wall/pus
silent stones
mirizzi’s syndrome - stone in GB presses on BD = jaundice
gallbladder necrosis
sx of biliary colic
sudden onset RUQ or epigastric pain - constant - as gallbladder contracts against obstruction
may radiate to R scapula
precipitated by fatty meal pr alcohol
lasts several hours
maybe nausea and vomiting
+- jaundice
sx of choledocholiuthiasis
RUQ pain >6hr
possible jaundice
signs of bilairy colic
RUQ/epigastric tenderness
ix for gallstones
bloods
- FBC
- blood cultures
- amylase - at risk of pancreatitis
USS
- demonstrates gallstones - acoustic shadow within the gallbladder
- increased thickness of GB wall
- dilatation of the biliary tree indicative of obstruction
AXR
- gallstones infrequently radio-opaque (10%)
- look for other causes of acute abdo
erect CXR - exclude perforation
ERCP
MRCP
PTC (percutaneous transhepatic cholangiography)
helical CT
urinalysis
ECG
ix fr choledocolithiasis
raised BR, GGT, ALP, AST, ALT
US - dilated bile duct, intrahepatic biliary dilatation
MRCP/ERCP = filling defect in contrast induced duct
mx for biliary colic
increased complications associated with late rather than early cholecystectomy so laparoscopic cholecystectomy at the initial presentation is the optimal approach. – if not possible they should be added to waiting list for surgery within 6 weeks
conservative
- for mild symptoms of biliary colic
- low fat diet
medical
- oral dissolution therapy is poorly effective - slow, and high recurrence rate
- severe biliary colic:
- admission
- NBM
- IV fluids
- analgesic
- anti-emetics
- if infection - AB
- if symptoms worsen or fail to get better: localised abscess or empyema should be suspected - drained percutaneously by cholecystostomy nad pigtail catheter
- if obstruction - urgent biliary drainage by ERCP or PTC
surgical - laproscopic cholecystectomy
mx for choledocholithiasis
supportive care, analgesics
endoscopic stone retrieval
elective cholecystectomy to prevent recurrence
complications of biliary colic
stones in CBD - can cause ascending cholangitis
stones at ampulla can cause ac pancreatitis
Porcelain gallbladder is a very rare complication, secondary to chronic inflammation and is a risk factor for malignant change – look for gallbladder mural calcification on radiograph
o Stones can migrate via a fistula into the bowel with impaction and obstruction (gallstone ileus).
Mucocele of the gallbladder is caused by a stone impacting in Hartmann’s pouch obstructing the cystic duct orifice. Mucous produced by the gallbladder produces gallbladder distension, discomfort and may become infected leading to empyema of the gallbladder.
comploications of stones in gallbladder
`
biliary colic
cholecystitis
mucocoele or gallbladder empyema
porcalain gallbladder
predisposition to gallbladder cancer (rare)
complications of stones outside gallbladder
- obstructive jaundice
- pancreatitis
- ascending cholangitis
- perforation and pericholecystic abscess or bile peritonitis
- cholecystenteric fistula
- gallstone ileus - eg bouveret’s syndrome - gallstones cause gastric outlet obstruction
- cholecystocholedochal fistula - mirrizi syndrome
complications of cholecystectomy
bleeding
infection
bile leak
bile duct damage (0.3% laproscopic, 0.2% open)
postcholecystectomy syndrome - persistent dyspeptic symptoms
post-site hernias
Px of gallstones
most cases benign and dont cause sig problems
surgery offers good chance of cure
