Gallstone Disease Flashcards
ESSENCE
Small stones that form within gallbladder, from concentrated bile in the bile duct
Most are made of cholesterol
What complications can they lead to
- Acute cholecystitis
- Acute cholangitis
- Pancreatitis
ANATOMY
Describe the relevent anatomy
- Right and left hepatic duct leave liver and join together to form common hepatic duct
- Cystic duct from gallbladder joints the common hepatic duct halfway along
- Pancreatic duct joins common hepatic duct further along, when they join it becomes ampulla of Vater which opens onto duodenum
- Sphincter of Oddi is ring of muscle surround ampulla of Vater that controls the flow of bile and pancreatic secretions into duodenum
ANATOMY
What is muscle around ampulla of Vater called
Sphincter of Oddi
AETIOLOGY
Risk factors
- Remember 4Fs
- Fat
- Fair
- Female
- Forty
Formation of gallstones is called
Cholelithiasis
AETIOLOGY
Pathophysiology
- Cholesterol cholelithiasis occurs due to 3 principle defects
- Bile supersaturated with cholesterol
- Accelerated nucleation
- Gallbladder hypomotility retaining abnormal bile
- Symptoms result when stones block cystic and/or bile ducts
- If blocks bile duct causing obstruction causes acute cholangitis
- If obstructs ampulla causes acute bilary pancreatitis
CLINICAL FEATURES
Presentation
- Asymptomatic 80%
- Bilary colic if stones blocking drainage of gallbladder
- Severe, colicky epigastric or right upper quadrant pain
- Often triggered by meals
- Lasting 30min-8 hours
- May be associated with nausea and vomiting
Why are patients with gallstones advised to avoid fatty food
- Fat entering digestive tract causes secretion of cholecystokinin (CCK) from duodenum
- This causes contractions of gallbladder, leading to bilary colid
INVESTIGATIONS
First choice
- Abdominal US - see stones
- Magnetic resonance cholangio-pancreatography (MRCP) if US doesnt show stones
- Possible endoscopic retrograde cholangio-pancreatography (ERCP)
- Maybe CT to look for differentials
- LFTs - normal if uncomplicated, deranged if complicated
- Serum lipase and amylase - pancreatitis
What are US findings
- Can identify
- Gallstones in gallbladder
- Gallstones in ducts
- Bile duct dilation (normaly <6mm)
- Acute cholecystitis
- Pancreas and pancreatic duct
Indication for ERCP
Clear stones in bile duct
Key compications of ERCP
- Excessive bleeding
- Cholangitis (infection in bile ducts)
- Pancreatitis
What do LFTs look at
- Bilirubin
- Alkaline phosphatase (ALP)
- Aminotransferases
- Alanine aminotransferase (ALT) and asparate aminotransferase (AST)
How are LFTs changed
- Raised bilirubin indicates obstruction to flow within biliary system, maybe obstruction due to gallstones
- Raised ALP
- Both raised but ALP raised higher - obstructive picture
Signs of raised bilirubin
- Jaundice
- Pale stools
- Dark urine
How does bilirubin normally drain
From liver, through bile ducts and into intestines
So if this is obstructed (by stones or external mass like tumour) bilirubin is raised
What is alkaline phosphatase (ALP)
- Enzyme originating in liver, biliary system and bone
- Abnormal result indicates liver or bone problem
- Often raised in pregnancy due to production by placenta
What are aminotransferases
- Alanine aminotransferase (ALT) and asparate aminotransferase (AST) are enzymes produced in liver
- Markers of hepatocellular injury (damage to liver cells)
What can be determined by changes in ALP compared to ALT/AST
Obstructive picture - higher rise in ALP than ALT and AST
Hepatic picture - higher rise in ALT and AST than ALP
MANAGEMENT
General principles
- Asymptomatic patients may be treated conservatively with no intervention
- With symptoms or complications are treated by cholecystectomy
What is cholecystectomy
- Surgical removal of gallbladder
- Can be laparoscopic or open using Kocher incision (right subcostal incision)
Complications of cholecystectomy
- Bleeding, infection, pain and scars
- Damage to the bile duct including leakage and strictures
- Stones left in the bile duct
- Damage to the bowel, blood vessels or other organs
- Anaesthetic risks
- Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
- Post-cholecystectomy syndrome
