Gall Stones

Question 1

What is the definition of gall stones?

Answer 1

Stone formation in the Gall bladder

Question 2

What are the different types of gall stone?

•How frequent are each of them?

Answer 2

Mixed stones - 80%
Pure cholesterol stones - 10%
Pigment stones - 10%

Question 3

What do mixed gall stones contain and what factors will increase the risk of mixed and pure cholesterol gall stones?

Answer 3

Mixed stones:
Contain cholesterol, calcium bilirubinate, phosphate and protein (80%).

Associated with 
•older age, female, 
•obesity, 
•parenteral nutrition, 
•drugs (OCP, octreotide), 
•family history, 
•ethnicity (e.g. Pima Indians), 
•interruption of the enterohepatic recirculation of bile salts (e.g. Crohn’s disease), 
•terminal ileal resection.

Pure cholesterol stones (10%): Similar associations as mixed stones.

Question 4

What types of pigment gall stones are there and what factors are likely to increase the risk of getting each of them?

Answer 4

Black stones made of calcium bilirubinate (⬆️ bilirubin secondary to haemolytic disorders, cirrhosis),
brown stones due to bile duct infestation by liver fluke Clonorchis sinensis.

Associated with haemolytic disorders (e.g. sickle cell, thalassemia,
hereditary spherocytosis).

Question 5

Describe the epidemiology of gall stones?
Effect of:
•age
•Sex ratio

Answer 5

Very common (UK prevalence~10%),

more common with age, 3* more females in younger population but equal sex ratio after 65 years.

Question 6

What would a patient with biliary colic describe in their history?

Answer 6

Sudden onset, severe right upper quadrant or epigastric pain, constant in nature.

May radiate to right scapula, often precipitated by a fatty meal.

Can last hours, may be associated nausea and vomiting.

Question 7

What would a patient with acute cholecystitis describe in their history?

Answer 7

Patient systemically unwell, fever, prolonged upper abdominal pain
that may be referred to the right shoulder (due to diaphragmatic irritation).

Question 8

What would a patient suffering ascending cholangitis describe in their history?

Answer 8

Classical association between right upper quadrant pain, jaundice and rigors (Charcot’s triad).

If combined with hypotension and confusion, it is known as Reynold’s pentad.

Question 9

What is charcot’s triad?

Answer 9

Jaundice
RUQ pain
Rigors

Question 10

What is Reynolds Pentad?

Answer 10

Charcot’s triad (jaundice, RUQ pain and rigours) with hypotension and confusion.

Question 10

What would you find on examination of a patient with biliary colic?

Answer 10

RUQ or epigastric tenderness.

Question 11

What would you find on examination of a patient with acute cholecystitis?

Answer 11

Tachycardia, pyrexia, right upper quadrant or epigastric tenderness.

•There may be guarding +/- rebound.
•Murphy’s sign is elicited by placing a hand at the costal margin in the RUQ and asking the patient to breathe deeply.
Patient stops breathing as the inflamed gallbladder descends and contacts the palpating fingers.

Question 12

How would you look for murphy’s sign?

Answer 12

Murphy’s sign is elicited by placing a hand at the costal margin in the RUQ and asking the patient to breathe deeply.
Patient stops breathing as the inflamed gallbladder descends and contacts the palpating fingers.

Question 13

What would you find on examination of a patient with ascending cholangitis?

Answer 13

Pyrexia, right upper quadrant pain, jaundice.

Question 14

What investigations would you perform on a patient with suspected gallstones?

Answer 14

Bloods:
•FBC (⬆️ WBC in cholecystitis or cholangitis),
•LFT (⬆️ AlkPhos, ⬆️ bilirubin in ascending cholangitis; there may be ⬆️ transaminases),
•blood cultures,
•amylase (risk of pancreatitis).

USS:
•Demonstrates gallstones (acoustic shadow within the gallbladder),
•⬆️ thickness of gallbladder wall and can examine for presence of dilatation of biliary tree indicative of obstruction.

AXR:
•Gallstones are infrequently radio-opaque (10%).

Other imaging:
•Erect CXR (to exclude perforation as a differential diagnosis),
•CT scanning,
•magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP).

Question 15

How would you manage a patient with gall stones, cholecystitis or cholangitis?

Answer 15

Mild symptoms: 
•Conservative, avoidance of fat in diet.

Sever biliary colic: 
•Admission, 
•IV fluids, 
•analgesia, 
•antiemetics 
•antibiotics if there are signs of infection (cholecystitis or cholangitis).

If symptoms fail to improve or worsen, a localized abscess or empyema should be suspected.
—This can be drained percutaneously by cholecystostomy and pigtail catheter.

If there is evidence of obstruction, urgent biliary drainage by ERCP or percutaneous transhepatic cholangiogram.

Surgical:
•Laparoscopic cholecystectomy +/- on table cholangiogram. In acute setting, performed within 72 h of symptom onset, or after several weeks for inflammation to settle.

Question 16

What complications could you expect for a patient with gall stones?
•consider gallstone location.

Answer 16

Stones within gallbladder: 
•Biliary colic, 
•cholecystitis, 
•mucocoele or gallbladder empyema, 
•porcelain gallbladder, 
•predisposition to gallbladder cancer (rare).

Stones outside gallbladder:
•Obstructive jaundice,
•pancreatitis,
•ascending cholangitis,
•perforation and pericholecystic abscess or bile peritonitis,
•cholecystenteric fistula,
•gallstone ileus,
•Mirizzi syndrome (common hepatic duct obstruction by an extrinsic compression from an impacted stone in the cystic duct),
•Bouveret’s syndrome (gallstones causing gastric outlet obstruction).

Question 17

What are the possible complications Of cholecystectomy?

Answer 17

Bleeding,
•infection,
•bile leak,
•bile duct injury (0.3% laparoscopic, 0.2% open),
•post-cholecystectomy syndrome (persistant dyspeptic symptoms),
•port-site hernias.

Question 18

What sort of prognosis would you expect for a patient with gallstones?

Answer 18

In most cases gallstones are benign and do not cause significant problems (2% with gallstones develop symptoms annually).

If they become symptomatic, surgery is an effective treatment.