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 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.
What is Mirrizi syndrome?
A stone located in Hartmanns pouch (outpouching of the gallbladder wall at junction of cystic duct) or in the cystic duct itself.
It can cause compression on the adjacent common hepatic duct.
Diagnosis of gallbladder empyema
US scan or CT scan
Fistula in gallbladder disease
Inflammation of the gallbladder can leads to fistula formation between gallbladder wall and small bowel.
This is termed a cholecystoduodenal fistula which leads to gallstones being passed directly into the small bowel.
