Diseases of the Gallbladder

Question 1

What percentage of the western population are affected by Gallstones?

Answer 1

10-14%; most of these individuals will remain asymptomatic, however on average 1-4% of individuals will develop symptoms secondary to their gallstones.

Question 2

Bile is formed from:

Answer 2

Cholesterol, phospholipids, and bile pigments (products of haemoglobin metabolism).

Question 3

What are the three main types of gallstones?

Answer 3

• Cholesterol stones - composed purely of cholesterol, from excess cholesterol production
• Pigment stones - composed purely of bile pigments, from excess bile pigment production
• Mixed stones - comprised of both cholesterol and bile pigments

Question 4

There is a well recognised link between cholesterol stones and:

Answer 4

Poor diet and obesity

Question 5

Pigment stones are commonly seen in those with:

Answer 5

Haemolytic anaemia

Question 6

Risk factors for gallstone disease:

Answer 6

5 F’s

• Fat
• Female
• Fertile
• Forty
• Family history

Also: pregnancy, oral contraceptives, haemolytic anaemia (specifically for pigment stones), and malabsorption (such as precious ileal resection or Crohn’s disease

Question 7

Biliary colic pathophysiology

Answer 7

The gallbladder neck becomes impacted by a gallstone. There is no inflammatory response, yet the contraction of the gallbladder against the occluded neck will result in pain.

Question 8

Biliary colic presentation

Answer 8

The pain is often focused in the right upper quadrant although it may radiate to the epigastrium and / or back.

The pain is typically sudden, dull and colicky in nature. The pain may be precipitated by the consumption of fatty foods and the patient often complains of nausea / vomiting.

Question 9

Why does eating fatty food exacerbate biliary colic?

Answer 9

Fatty acids stimulate the duodenum endocrine cells to releas cholecystokinin (CKK), which in turn stimulates contraction of the gallbladder.

Question 10

Presentation of acute cholecystitis

Answer 10

Constant pain in the RUQ or epigastrium, associated with signs of inflammation, such as fever or lethargy.

May demonstrate a positive Murphy’s sign.

Question 11

Describe Murphy’s sign

Answer 11

Whilst applying pressure in the RUQ, ask the patient to inspire. Murphy’s sign is positive when there is a halt in inspiration due to pain, indicating an inflamed gallbladder.

(This can be achieved more accurately with a ultrasound, namely the sonogrphic Murphy sign.)

Question 12

Differential diagnosis for RUQ pain:

Answer 12

• Biliary colic
• Cholecystitis
• GORD
• Peptic ulcer disease
• Acute pancreatitis
• Inflmmatory bowel disease

Question 13

Laboratory investigations for gallstone disease:

Answer 13

• FBC and CRP - assess for the presence of any inflammatory response, which will be raised in cholecystitis
• LFTs - biliary colic and acute cholecystitis are likely to show a raised ALP (indicating ducal occlusion), yet ALT and bilirubin should remain within normal limits (unless a Mirizzi syndrome)
• Amylase or lipase - to check for any evidence of pancreatitis
• Urinalysis

Question 14

Imaging in gallbladder disease

Answer 14

• Trans-abdominal ultrasound is typically first line
• If results from USS are inconclusive, magnetic resonance cholangiopancreatogrphy can be used

Question 15

Three specific areas are often visualised on US:

Answer 15

• The presence of gallstones or sludge (the start of gallstone formation)
• Gallbladder wall thickness (if thick walled, then inflammation is likely)
• Bile duct dilation (indicates a possible stone in the distal bile ducts)

Question 16

Management of biliary colic

Answer 16

• Regular analgesia (paracetamol +/- NSAIDs +/- opiates)
• Advise on lifestyle factors: low fat diet, weight loss, and increasing exercise
• Elective laparoscopic cholecystectomy within 6 weeks of first presentation

Question 17

Why is cholecystectomy offered following biliary colic?

Answer 17

There is a high chance of symptom recurrence or the development of complications of gallstones.

Question 18

Acute cholecystitis managment

Answer 18

• Appropriate intravenous antibiotics (such as co-amoiclav +/- metronidazole)
• Analgesia and antiemetics
• Laparoscopic cholecystectomy is indicated within 1 week of presentation (however this ideally should be done within 72 hours of presentation for a likely simpler procedure)

Question 19

What procedure can be performed on patients with acute cholecystitis who are not fit for surgery and are not responding to antibiotics?

Answer 19

A percutaneous cholecystostomy can be performed to drain the infection (although as the gallstones remain n situ, the risk of recurring diseas remains).

Question 20

What needs to be excluded in patients readmitted with RUQ pain post-cholecystectomy?

Answer 20

It is important to exclude a retained CBD stone post-operatiely. US abdomen scan may be useful, yet if this is unremarkable, then further investigation via MRCP imaging is warranted.

Question 21

What is Mirizzi syndrome?

How is it diagnosed?

Management?

Answer 21

A stone located in Hartmanns pouch (an out-pouching of the gallbladder wall at the junction with the cystic duct) or in the cystic ductitself can cause compression on the adjacent common hepatic duct.

This results in an obstructive jaundice, even without stones being present within the lumen of the common hepatic or common bile ducts.

Diagnosis is confirmed by MRCP.

Management with laparoscopic cholecystectomy.

Question 22

Gallbladder empyema

1) What is it?
2) Presentation
3) Diagnosis
4) Management

Answer 22

1) The gallbladder becomes filled with pus
2) Patients will become unwell, often septic, presenting with a similar clinical picture to acute cholecystitis.
3) Condition is diagnosed by either USS or CT.
4) Laparoscopic cholecystectomy or percutaneous cholecystostomy (if unsuitable for surgery)

Question 23

Chronic cholecystitis

1) What is it?
2) Presentation?
3) Diagnosis?
4) Managment?
5) Complications?

Answer 23

1) Patients with chronic cholecystitis will typically have a history of recurrent or untreated cholecystitis, which has led to a persistent inflammation of the gallbladder wall.
2) Patients present with ongoing RUQ or epigastric pain with associated nausea and vomiting.
3) It can be diagnosed typically by CT imaging (or often noted on histology post-cholecystectomy).
4) Management in uncomplicated cases is via elective cholecystectomy.
5) Its main complications are gallbladder carcinoma and biliary-enteric fistula.

Question 24

Inflammation of the gallbladder (typically if recurrent) can cause a fistula to form between the gallbladder wall and the small bowel (Fig. 7), termed a cholecystoduodenal fistula, allowing gallstones to pass directly into the small bowel (typically at the duodenum).

Which syndromes can this result in?

Answer 24

• Bouveret’s Syndrome – a stone impacts in the proximal duodenum, causing a gastric outlet obstruction
• Gallstone Ileus – a stone impacts at the terminal ileum (the narrowest part of the small bowel), causing a small bowel obstruction. (The term ileus is misleading as it is actually a bowel obstruction).