Cholelithiasis and Biliary Colic

Question 1

Define the following terms: 1) Cholelithiasis
2) Choledocholithiasis
3) Biliary colic
4) Acute cholecystitis
5) Acute cholangitis

Answer 1

1) gall stones
2) gallstones within the biliary tree
3) refers to self-limiting pain in the RUQ associated with gall stones
4) acute inflammation of the gallbladder
5) infection of the biliary tree, commonly due to an obstructing stone in the common bile duct.

Question 2

What are risk factors associated with gall stones?

Answer 2

• Increasing Age
• Female sex
• Genetic predisposition
• Obesity
• Rapid weight loss / prolonged fasting
• Diabetes
• Medications (e.g. hormone (oestrogen) replacement therapy, ceftriaxone, octreotide)
• Crohn’s disease
• Diet (high in triglycerides, refined carbohydrates)

Question 3

What would black pigment stones indicate?

Answer 3

Increased red cell turnover

Question 4

What happens in Mirrizi’s syndrome?

Answer 4

Hartmanns pouch refers to dilatation or outpouching at the neck of the gallbladder. Stones may impact here causing extrinsic compression of the extrahepatic bile duct leading to Mirrizi’s syndrome.

Question 5

What is bile composed of? What causes stone formation?

Answer 5

• bile acids
• phospholipid
• bilirubin
• cholesterol
• water

Imbalance in composition and stasis leads to stone formation.

Question 6

What are the different types of gall stones; describe them briefly.

Answer 6

1) Cholesterol- most common type
2) Black pigment stones- occur in people with increased amounts of bilirubin, and in patients with increased hemolysis.
3) Brown pigment stones- mostly occur in association with infection and may develop de novo in the bile duct after cholecystectomy.

Question 7

What are the clinical features of biliary colic?

Answer 7

• intermittent RUQ/epigastric pain
• N&V

Question 8

What investigations would you do for a biliary colic?

Answer 8

• Ultrasound
• LFTs

Question 9

What is the management for biliary colic?

Answer 9

• analgesia
• diet (a low fat diet)

Surgical intervention:
- If stone present in the CBD- MRCP +/- ERCP: MRCP allows for confirmation of stones in the biliary tree. If present ERCP allows for therapeutic intervention with stone retrieval, sphincterotomy and stent placement prior to cholecystectomy.
- on-table cholangiogram- less commonly available and technically challenging.