Biliary Tract Disease: Cholethiasis + Biliary Colic

Question 1

Cholethiasis Definition

Answer 1

Gallstones = small solid stones that form within the gallbladder
Made up of cholesterol, pigment (Px w/ haemolytic disorders like sickle cell) or mixed
= most common type is cholesterol due to increased cholesterol, reduced bile salts and biliary stasis

Question 2

Epidemiology

Answer 2

Fat (BMI >40)
Female
Forty
Fertile

Question 3

Risk factors

Answer 3

Family history
Rapid weight loss
Diabetes mellitus
Crohns disease: bile acid malabsorption
Medication: oral contraceptive pill and hormone replacement therapy due to the presence of oestrogen, fibrates also increase the risk
Haemolytic conditions: haemolysis (sickle cell disease) causes excess circulating bilirubin resulting in pigment gallstones
NAFLD

Question 4

Aetiology

Answer 4

Biliary stasis
- when fasting GB is not contracting
- high oestrogen
- taking oral contraceptive pill
- spinal cord injury
Increased cholesterol
- obesity
- Crohn’s
- diabetes
Decreased bile acids - with fewer bile acids they cannot surround the lipid to emulsify it
- cirrhosis
- Crohn’s
- Ileal resection (bile acids not being reabsorbed)

Question 5

Biliary colic defintion

Answer 5

Intermittent right upper quadrant pain caused by gallstones irritating the cystic duct

Question 6

Pathophysiology

Answer 6

Gall stones temporarily blocking the cystic duct without signs of cystic inflammation
Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum CCK triggers contraction of the gall bladder + allows the sphincter of Oddi to relax so the bile and pancreatic enzymes can enter the duodenum
After a fatty meal, when the gall bladder contracts the gall stone can get lodged in the cystic duct = causes biliary colic pain
The gall stone can fall back into the gall bladder the pain goes away
Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.

Question 7

Aetiology

Answer 7

Caused by stones temporarily obstructing drainage of the gall bladder after lodging in the cystic duct
When it falls back into the gall bladder the symptoms resolves

Question 8

Signs + Symptoms

Answer 8

Right upper quadrant pain or epigastric abdominal pain
- may radiate to epigastrium, right shoulder + back (irritation of phrenic nerve)
- triggered by eating fatty meal (triggers gall bladder to contract against blockage)
- lasts between 30 mins and 8 hours
- pain may resolve if the gall stone falls back into CB
- common at night as laying flat makes it easier to get lodged in the cystic duct
Nausea and vomiting = COMMON
Sweating

Murphy’s sign negative: on palpation of the right upper quadrant there is no arrest of inspiration
Pain is often reproduced after eating, but not on palpation

Question 9

DONT GET CONFUSED BY ALTERNATIVE GALL STONE RELATED DISEASE

Answer 9

Cholecystitis: RUQ tenderness, positive murphy’s sign, and fever
Ascending cholangitis: Charcot’s triad (jaundice, fever, RUQ pain)
Common bile duct stone: features of obstructive jaundice (jaundice, pale stools, dark urine, pruritus)

Question 10

Diagnosis

Answer 10

FIRST LINE = Abdo USS
- Stones in GB + ducts
GOLD STANDARD = Endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) = sensitive and specific. Used if cant see stone but there is dilation +/or abnormal LFTs
LFTs:
-Raised ALP +bilirubin
- ALT normal
= OBSTRUCTIVE PICTURE
Investigations to consider = FBC + CRP may suggest cholecystitis

Question 11

Management

Answer 11

FIRST LINE = NSAIDS/ Analgesia (mild to moderate)
- severe pain: IM diclofenac, then IM opioid (morphine) if diclofenac not effective or CI
GOLD STANDARD = Elective laparoscopic cholecystectomy = refer all people with symptomatic gall stones
- Life style changes: avoid fatty foods, increase fibre intake, whilst awaiting cholecystectomy
If found incidentally, the patient has been asymptomatic, surgery NOT recommended

Question 12

Complications

Answer 12

Obstructive jaundice,
Cholecystitis,
Ascending cholangitis
Acute pancreatitis: gallstones are the most common cause
Gallbladder empyema
Post-cholecystectomy syndrome: Involves group of non-specific symptoms that can occur after a cholecystectomy. May be attributed to change in bile flow after after removal of the gall bladder:
- Diarrhoea
- Indigestion
- Epigastric or RUQ pain + discomfort
- Nausea
- Intolerance of fatty foods
- Flatulence