Gallstone disease Flashcards
Name five risk factors for gallstone disease
‘Fair, Fat, Fertile, Female, Forty’
- Previous gallstones; FHx
- Diet high in triglyceriders and refined carbs; low fibre
- Obesity; NAFLD
- Increasing age
- Rapid weight loss: XS cholesterol in bile
- Diabetes; Crohn’s disease
- COCP; HRT: oestrogen raises HMG-CoA reductase activity
Name five complications of gallstones disease
- Biliary colic
- Acute cholecystitis
- Acute pancreatitis
- Obstructive jaundice; Mirizzi syndrome
- Ascending cholangitis
- Fistula; Bouveret’s syndrome
- Biliary peritonitis
- Gallbladder mucocele
- Association with gallbladder cancer
Define biliary colic
Sudden pain in the epigastrium or RUQ
- May radiate to the right inferior scapular region
- Steady non-paroxysmal typically lasting for 30m - 8h
- NaV
Differentiate biliary colic, acute cholecystitis, and cholangitis
- Biliary colic:
- RUQ pain
- Acute cholecystitis:
- RUQ pain and tenderness + fever/raised WCC
- Cholangitis:
- RUQ pain + fever (often rigors)/raised WCC + jaundice
What is Murphy’s sign?
Sign suggestive of acute cholecystitis
Pain and arrest of inspiration on palpation of the RUQ at costal margin when the patient inhales
Similar manoeuvre in LUQ should not elicit discomfort
How does chronic cholecystitis present?
- Recurrent biliary colic (RUQ pain) and RUQ tenderness
- Absent fever (unlike acute cholecystitis)
May not be accompanied by gallbladder inflammation
Inflammation not correlated with biliary colic intensity or frequency
Outline Charcot’s cholangitis triad
Ascending cholangitis (50-70% present)
- Fever, often with rigors
- Jaundice
- RUQ abdominal pain
- Reynold’s pentad: essential surgical decompression
- Addition of hypotension + altered mental state
State Reynold’s pentad and its significance
- Fever, often with rigors
- Jaundice
- RUQ pain
- Mental state changes
- Hypotension
Suggestive of severe acute obstructive cholangitis
Surgical decompression is essential (preferably ERCP)
What is ascending cholangitis?
Infection of the bile duct (cholangitis) due to bacteria ascending from the ampulla of Vater. Typically involves partial obstruction.
Common organisms:
- Klebsiella spp.
- E. coli
- Enterobacter spp.
- Enterococci
- Streptococci
Name three causes of cholangitis
Bacterial infection of bile duct secondary to partial blockage:
- Gallstones
- ERCP
- Tumours
- Pancreatic cancer
- Cholangiocarcinoma
- Ampullary cancer
- Metastasis
- Bile duct stricture or stenosis
- May have parasitic infection
What is a gallbladder mucocele?
Gallbladder distention due to inappropriate accumulation of mucus due to outlet obstruction
Request three investigations for gallstone disease
-
Abdominal USS: 90-95% sensitive for gallstones
- Common bile duct dilation (>6mm)
- LFTs, FBC
- Serum amylase
- Blood cultures
- MRCP or Endoscopic USS
Outline the management of asymptomatic gallstones
No treatment required if asymptomatic gallstones are found in a normal gallbladder, with a normal biliary tree
Asymptomatic gallstones are very common
Refer if located in common bile duct
When is gallstones disease indicated for surgery?
- Symptomatic gallstone disease
- Asymptomatic gallstones within the common bile duct
- High risk of complications in gallstones disease
Outline the management of symptomatic gallstones
- Adequate analgesia
- Severe: IM diclofenac; consider opioids
- Mild-moderate: paracetamol or NSAID
- ERCP + laparoscopic cholecystectomy
- Common bile duct stones
- Laparoscopic cholecystectomy
- Early: within 1 week of developing acute cholecystitis
- Consider percutaneous drainage of gallbladder empyema
- If surgery is contraindicated and conservative failed
- Consider low-fat diet to help prevent biliary pain
What is Calot’s triangle?
Anatomical zone used to define the usual path of the cystic artery, cystic duct, and common hepatic duct.
Important during a cholecystectomy so as to correctly ligate and cut the cystic artery and cystic duct.
Borders:
- Superior: Inferior liver surface
- Inferior: Cystic duct
- Medial: Common hepatic duct
What is Courvoiser’s law?
- Palpable gallbladder in the presence of jaundice
- Jaundice is unlikely to be due to stones
- Cholangiocarcinoma or pancreatic head tumour
- Stones cause thickened and fibrosed gallbladder
- Thus not palpable
