Gallstone Disease

Question 1

What causes gall stones?

Answer 1

Bile stays in the gall bladder too long. Anything that keeps the bile in the gallbladder for longer will facilitate stone formation. Gallbladder dysmotility is exactly that—bile staying in the gallbladder too long. This occurs due to

—-rapid weight loss,
—-prolonged fasting, and
—-biliary dyskinesia.

You should know three stone types: cholesterol (green), pigmented (black), and brown

Question 2

What are the different types of gall stones?

Answer 2

Question 3

_________________ gallstones are the most common type and are green in color.

Answer 3

Cholesterol

Question 4

What are the risk factors for cholesterol gall stones?

Answer 4

Risk factors are the “five F’s:” female, fertile (pregnant), fat (obesity), forty (middle age most common), and fNative American (the F is silent).

Question 5

What is the main contributing factor to pigemneted gallstones?

Answer 5

Hemolysis!

Pigmented stones of the gallbladder are black, made of mostly unconjugated bilirubin,and caused by hemolysis. Pigmented gallstones can occur in children with hereditary causes of hemolytic anemia. Cholesterol stones do not form in kids.

Question 6

Where do brown stones come from?

Answer 6

Brown stones are not gallbladder stones but rather primary stones of the biliary tree. They are caused by bacterial infection of the biliary tree, resulting in bacterial β-glucuronidase deconjugating bilirubin. They do not sit in the gallbladder with other stones, so their surface is smooth, whereas gallstones are more jagged.

Question 7

Where are the major places you can get a gallstone stuck?

Answer 7

in the gallbladder, the cystic duct, or the common bile duct

Question 8

How does the work up for gallstones in the gallbladder differ from those stuck in the common bile duct?

Answer 8

Gallstones in the gallbladder primarily present with right upper quadrant (RUQ)pain and a tender, inflamed gallbladder.This should be worked up with a RUQ ultrasound, and it is corrected with cholecystectomy. Gallstones in the common bile duct also present with pain, but because the common bile duct is occluded, there will be jaundice and elevated L F Ts (and lipase, if the pancreas is involved). The work-up begins with a RUQ ultrasound but will need an MRCP to evaluate, ERCP to treat, and subsequent follow-up cholecystectomy.

Question 9

Answer 9

Question 10

Answer 10

Question 11

Answer 11

Question 12

is an obstructing gallstone without infection or superimposed pancreatitis, as the obstruction is proximal to the hepatopancreatic ampulla.

Answer 12

choledocolithasis

Question 13

Answer 13

Question 14

Answer 14

Question 15

Answer 15

Question 16

What is an ERCP?

Answer 16

An EGD that cannulates the hepatopancreatic sphincter (aka the sphincter of Oddi); uses a wire to infuse contrast dye, cut the sphincter (if necessary), and slip a retrieval balloon behind the stone; inflates the balloon; and yanks the stone out through the hepatopancreatic ampulla and sphincter.

Question 17

When is a HIDA scan warranted?

Answer 17

HIDA scans can help provide definitive dx for biliary dyskinesia (failure of the gallbladder to empty fully on HIDA) and cholecystitis (failure of the gallbladder to fill on HIDA) are biliary pathologies you studied in this lesson, and both are diagnosed definitively by HIDA scan.

The question is whether she simply has symptomatic cholelithiasis or she has acute cholecystitis. If the ultrasound does not reveal what you need it to, the best way to determine is via HIDA scan, which is a nuclear tracer. If the gallbladder does not light up with tracer, there is an obstruction preventing the tracer from entering the gallbladder, an obstruction of the cystic duct. That is the same thing as saying an obstruction preventing bile from the gallbladder through the cystic duct. And thus, the diagnosis of acute cholecystitis is made. This is important because untreated cholecystitis will eventually lead to necrosis and perforation, whereas symptomatic cholelithiasis can be managed electively. When the diagnosis is certain, but the ultrasound doesn’t strictly agree, get a HIDA nuclear scan.

Question 18

Reynolds pentad

Answer 18

RUQ, jaundice, fever, AMS, and hypotension

Question 18

RUQ, jaundice, and fever

Answer 18

charcot’s triad

Question 19

What is concerning with reynolds pentad?

Answer 19

Septic shock , seen in ascending cholangitis

Question 20

How do we address ascending cholangitis?

Answer 20

ERCP

Question 21

What is charcot’s triad concerning for?

Answer 21

Ascending cholangitis

Question 22

obstructive pattern on LFTs, sepsis by vitals and CBC and charcot’s triad

Answer 22

ascending cholangitis

Question 23

What kind of orgnaisms cause ascending cholangitis?

Answer 23

The organisms that cause ascending cholangitis ascend from the gut. It is typically associated with gram-negative organisms and anaerobes. The goal is to use targeted therapy to ensure coverage of all likely organisms but not to give too much coverage for unnecessary organisms. In this case, ampicillin + sulbactam covers the gram-negatives, while metronidazole covers the anaerobes. Thus, the right answer is ampicillin-sulbactam and metronidazole.

Question 24

Fat female w/A right upper quadrant ultrasound shows biliary sludging and gallstones without pericholecystic fluid. The gallbladder wall is mildly thickened.
What is the best next step in the management of this patient?

Answer 24

HIDA SCAN

The question is whether she simply has symptomatic cholelithiasis or she has acute cholecystitis. If the ultrasound does not reveal what you need it to, the best way to determine is via HIDA scan, which is a nuclear tracer.

Question 25

What is circled in green on this liver US?

Answer 25

Pericholecystic fluid- note the mixed echogenicity

Question 26

Where would the obstructing stone be on this US? Can we see it?

Answer 26

Although there are stones to the right (note the hypoechoic shadow marked by the red arrow), the obstructing stone would be where the green dot is and we often dont see it on US

Question 27

Gallstones in the common bile duct can cause what ?

Answer 27

Gallstones in the common bile duct can be choledocholithiasis, ascending cholangitis, or gallstone pancreatitis.

Question 28

When may you see jaundice in a gallstone based problem?

Answer 28

Gallstones in the common bile duct also present with pain, but because the common bile duct is occluded, there will be jaundice and elevated LFTs (and lipase if the pancreas is involved).

Question 29

Why do you see jaundice in choledocolethiasis and not cholecystitis?

Answer 29

Blockage of the common bile duct in choledocolethiasis!

Question 30

Give a breif overview of the different gall stone problems in the gallbladder

Answer 30

Question 31

What do gall stones look like on imaging?

Answer 31

Question 32

breif overview of gallstone problems in the common bile duct

Answer 32

Question 33

What symptoms should you be aware of for gallstone pancreatitis?

Answer 33

anorexia, epigastric pain, nausea, vomiting—and the labs reflect pancreatitis—elevated lipase and amylase. Ultrasound will show common bile duct dilation. MRCP confirms that the stone is there. ERCP is performed to retrieve the stone. Cholecystectomy is performed before discharge. Gallstone pancreatitis warrants urgent ERCP.

Question 34

__________________________ should be suspected in a pt with gallstone pancreatitis who also has fecers, RUQ pain, jaundice, altered mental status, and hypotension

Answer 34

acute cholangitis