Biliary Colic and Cholecystitis Flashcards
Epidemiology
Common condition affecting around 10-14% of the western pop.
Usually asymptomatic but 1-4% will develop symptoms secondary to their gallstones.
What can gallstones cause?
A spectrum of disease from biliary colic to pancreatitis as well as acute cholecystitis
What is bile formed from?
Cholesterol
Phospholipids
Bile pigments
It is stored in the gallbladder before passing into duodenum upon gallbladder stimulation.
Three main types of gallstones
Cholesterol stones (purely cholesterol due to excess cholesterol production)
Pigment stones (purely of bile pigments from excess bile pigment production)
Mixed stones (cholesterol + bile pigment)
Association with cholesterol stones
Poor diet
Obesity
Cholesterol stones
Association with pigment stones
Haemolytic anaemia
Explain the biliary system
Risk factors of gallstone disese
5Fs
Fat
Female
Fertile
Forty
Family history
Prengnancy, oral contraceptives, haemolytic anaemia and malabsorption.
Clinical features
50% will have biliary colic
35% will have acute cholecystitis
Explain biliary colic
Occurs when gallbladder neck becomes impacted by the gallstone
There is no inflammation.
Contraction of the gallbladder against the occluded neck will lead to pain.
Clinical features of biliary colic
Sudden, dull and colicky pain.
RUQ pain that may radiate to epigastric area +/- the back.
The pain can be precipitated by constumption of fatty foods (fatty acids leads to release of CCK -> stimulates contraction)
N+V might occur
Once pain relief has started symptoms often settle
Clinical features of acute cholecystitis
Constant pain in the RUQ +/- epigastric area
Signs of inflammation like fever and lethargy
Tender RUQ and may show +ve Murphy’s sign
Check for any guarding (gallbladder perforation) and features of sepsis.
Explain Murphy’s sign
When applying pressure in the RUQ ask the patient to inspire.
+ve = Halt in inspiration due to pain.
This indicates inflamed gallbladder
This can be achieved more accurately with an ultrasound called sonogrpahic Murphy sign.
Dx
GORD
Peptic ulcer disease
Acute pancreatitis
IBD
Lab tests
FBC and CRP = elevated in cholecystitis
LFTs = Biliary colic and acute cholecystitis will likely show ALP elevation, ALT and bilirubin should remain within normal limits.
Amylase to check for evidence of pancreatitis
Urinalysis and pregnancy test should be performed as well.
First line imaging
Trans-abdominal ultrasound
What three specific areas are visualised on US
Presence of gallstones or sludge
Gallbladder wall thickness (thick wall in inflammation)
Bile duct dilatation (indicates stone in the distal bile ducts)
What should any patient suggestive of gallstones with inconclusive US (or CT scan) undergo?
Magnetic Resonance Cholangiopancreatography (MRCP) which is the gold standard investigation.
It can show potential defects in the biliary tree.
General management of biliary colic.
Analgesia (paracetamol and or NSAIDs and or opiates)
Lifestyle advice about…
Low fat diet, weight loss, increasing exercise.
There is a high chance of symptom recurrence in Biliary colic or development of complications.
What should be done?
Elective laparoscopic cholecystectomy.
Should be offered within 6 weeks of first presentation.
General management of acute cholecystitis.
IV abx such as co-amoxiclav +/- metronidazole
Analgesia and anti-emetics should also be given.
Indications of surgery in acute cholecystitis.
Indicated within 1 week of presentation.
Should be done 72hrs of presentation if possible.
Surgery in acute cholecystitis
Laparoscopic cholecystectomy.
For those not fit for surgery and not responding to abx, what can be done?
Percutaneous cholecystostomy to drain infection.
Gallstones remain in-situ however.
