Chapter 53: Biliary tract- Cholelithiasis

Question 1

What is it?

Answer 1

Formation of gallstones

Question 2

What is the incidence?

Answer 2

≈10% of U.S. population will develop gallstones

Question 3

What are the “Big 4” risk factors?

Answer 3

“Four Fs”:

1. Female
2. Fat
3. Forty
4. Fertile (multiparity)

Question 4

What are the types of stones?

Answer 4

Cholesterol stones (75%)

Pigment stones (25%)

Question 5

What are the types of pigmented stones?

Answer 5

1. Black stones (contain calcium bilirubinate)
2. Brown stones (associated with biliary tract infection)

Question 6

What are the causes of black-pigmented stones?

Answer 6

1. Cirrhosis
2. hemolysis

Question 7

What is the pathogenesis of cholesterol stones?

Answer 7

Secretion of bile supersaturated with cholesterol (relatively decreased amountsof lecithin and bile salts); then, cholesterol precipitates out and forms solid crystals, then gallstones

Question 8

What are the signs and symptoms?

Answer 8

Symptoms of:

• biliary colic
• cholangitis
• choledocholithiasis
• gallstones
• pancreatitis

Question 9

Is biliary colic pain really “colic”?

Answer 9

No, symptoms usually last for hours; therefore, colic is a misnomer!

Question 10

What percentage of patients with gallstones are asymptomatic?

Answer 10

80% of patients with cholelithiasis are asymptomatic!

Question 11

What is thought to cause biliary colic?

Answer 11

Gallbladder contraction against a stone temporarily at the gallbladder/cystic ductjunction; a stone in the cystic duct; or a stone passing through the cystic duct

Question 12

What are the five major complications of gallstones?

Answer 12

1. Acute cholecystitis
2. Choledocholithiasis
3. Gallstone pancreatitis
4. Gallstone ileus
5. Cholangitis

Question 13

How is cholelithiasis diagnosed?

Answer 13

History

Physical examination

Ultrasound

Question 14

How often does ultrasound detect choledocholithiasis?

Answer 14

≈33% of the time … not a very good study for choledocholithiasis!

Question 15

How are symptomatic or complicated cases of cholelithiasis treated?

Answer 15

By cholecystectomy

Question 16

What are the possible complications of a lap chole?

Answer 16

• Common bile duct injury
• right hepatic duct/artery injury
• cystic duct leak
• biloma (collection of bile)

Question 17

What are the indications for cholecystectomy in the asymptomatic patient?

Answer 17

• Sickle-cell disease
• Calcified gallbladder (porcelain gallbladder)
• Patient is a child

Question 18

What is choledocholithiasis?

Answer 18

Gallstones in the common bile duct

Question 19

What is the management of choledocholithiasis?

Answer 19

• ERCP with papillotomy and basket/balloon retrieval of stones (pre- or postoperatively)
• Laparoscopic transcystic duct or trans common bile duct retrieval
• Open common bile duct exploration

Question 20

What medication may dissolve a cholesterol gallstone?

Answer 20

Chenodeoxycholic acid, ursodeoxycholic acid (Actigall®); but, if medication isstopped, gallstones often recur

Question 21

What is the major feared complication of ERCP?

Answer 21

Pancreatitis