Cholelithiasis

Question 1

Risk factors

Answer 1

Forty
Female
Fertile
- estrogenic influence ; reduce activity of 7 alpha hydroxylase and reduce gallbladder motility
Family history
-first degree relation
Fat

Question 2

Name 3 main types of gallstone

Answer 2

1)Cholesterol
2)Pigment
3)Mixed stone

Question 3

Pathophysiology of gallstones

Answer 3

Formation is due to disruption in the solubility equilibrium of bile
1. Increased cholesterol secretion in bile
-obesity
-estrogen influence
2. Decreased emptying of the gallbladder
-gallbladder malignancy
-gallbladder hypomotility
-pregnancy
-fasting , Total Parenteral Nutrition

Question 4

Pigment stone further divided into

Answer 4

Brown and Black stone

Question 5

Black (sterile) stone pathophysiology

Answer 5

Formation is due to
- Increased secretion of bilirubin conjugates into bile – haemolytic disorders (i.e. G6PD, sickle cell,
spherocytosis), cirrhosis, terminal ileal resection (loss of bile salts)
- Gallbladder hypomotility – chronic Total Parenteral Nutrition
- Decreased bilirubin solubilizes, and bile stasis

Question 6

Brown pigment stone pathophysiology

Answer 6

-Infection
-Biliary stasis

Question 7

3 clinical stages of cholelithiasis

Answer 7

• asymptomatic
• symptomatic
• complicated

Question 8

How does symptomatic cholelithiasis presented ?

Answer 8

Biliary colic

• Site – epigastric (70%) or RHC pain – can be epigastric because embryonically gallbladder is in the midline
• Onset – usually occur within hours of eating a meal often awakening patient from sleep
• Character – not a true colic – waxing-and-waning character but rarely have pain free intervals – basal pain due to inflammation
  of ductal epithelium and proximal distention

-Radiation – inferior angle of scapula or tip of right shoulder

• Alleviating – not relieved by squatting, bowel movement, or flatus
• Timing – distinct attacks lasting 30 mins to several hours, often resolves spontaneously by 6 hours (if > 6hrs, suspect
  complications such as acute cholecystitis)
• Exacerbating – not worse with movement
• Severity – steady and intense pain
• Associated symptoms (poor predictive value for gallstone disease)
  ▪ N/V, patient gets better after vomiting
  ▪ Bloating, abdominal distention
  ▪ Epigastric or retrosternal burning sensation
  ▪ Back pain, LUQ pain

Ddx of biliary colic : acute cholecystitis , infectious disease (hepatitis) , gastritis , peptic ulcer disease , pancreatitis

Question 9

Complicated gallstones is gallstones + its complication . So what is the complication of gallstone

Answer 9

Sequelae
* Acute / chronic cholecystitis
* Mucocele
* Empyema
* Gangrene
* Carcinoma
* Perforation
* Mirrizi’s syndrome - obstruction of the common hepatic duct

Question 10

Investigation

Answer 10

Ultrasound of hepatobiliary system

• Investigation of choice for gallstones (92% sensitivity, 99% specificity)
• Even more sensitive than CT scan for stones since CT may miss small stones due to the spacing of the cuts taken
• Features of stone on ultrasound: strong echogenic rim around the stone, with posterior acoustic shadowing
• Bile should appear as black patch in gallbladder; if not homogeneous then likely to have biliary sludge

Question 11

Principle of management

Answer 11

Asymptomatic
-dietary modification : avoid fats and large meals
-close follow up

Symptomatic
-surgery
indication for surgery
* abdominal pain with ultrasound proven stones
* recurrent attack
* biliary colic that radiate to the back
* positive response to simple analgesics

If the pain is related to gallstones causing inflammation or irritation, the patient may experience a positive response to these medications.
If negative response it can be , digestive issue ; GERD , or muscle strain ,