Gallstones (1)

Question 1

What are its 3 types?

What are its risk factors?

Which investigations should be done?

Answer 1

➊ • Cholesterol (90%) - Large, yellow stones
• Pigment/Bilirubinate - Small, pigmented stones
• Mixed

➋ 4 F’s:
• Fair
• Fat
• Female
• Forty

➌ • USS
• LFT - Bilirubin, AST/ALT, ALP, GGT
‣ ALP and GGT will be raised with biliary obstruction

Question 2

Biliary Colic:
What occurs here?

How does it present?

Why do fatty meals worsen the pain?
→ Therefore, how is the colic managed?

Answer 2

➊ Stone blocks neck of gallbladder or cystic duct, so gallbladder contracts against the obstruction

➋ • Colicky RUQ pain (may radiate to back/tip of scapula)
• Worse after eating esp. a fatty meal
• N+V
• Murphy’s -ve

➌ When fat enters the gut, CCK is released from the duodenum, which triggers gallbladder contraction
→ Avoid fatty foods (prevents CCK release and gallbladder contraction)

Question 3

Acute Cholecystitis:
What occurs here?

How does it present?

Answer 3

➊ Stone blocks neck of gallbladder or cystic duct for a long period of time, rubbing against and damaging the mucosal lining → inflammation

➋ • RUQ/Epigastric pain (radiating to right shoulder tip if diaphragm is irritated)
• Fever
• N+V
• Murphy’s +ve

Question 4

Ascending Cholangitis: (Biliary Sepsis)
What occurs here?

How does it present?

How is it investigated?

How is it managed?

Answer 4

➊ Blockage of CBD causing stasis, and bacterial infection of the biliary tree

➋ Charcot’s Triad - Fever, Jaundice, RUQ pain

➌ • Abdomen US
• MRCP

➍ • IVF and Abx
• ERCP
• Cholecystectomy

Question 5

Acute Pancreatitis:
What occurs here?

How does it present?

Answer 5

➊ Stone blocks ampulla of vater, leading to a backup of pancreatic secretions, auto-digestion, and inflammation

➋ • Stabbing-like, epigastric pain which radiates to the back and is relieved by sitting forward or lying in foetal position
• Vomiting

Question 6

Gallstone Ileus: (Rare)
What occurs here?

What signs on imaging highly suggest this?

Answer 6

➊ • Gallstone erodes through gallbladder wall, forming a fistula between the gallbladder and small bowel
• If a large gallstone moves through this fistula, it can get trapped in narrow areas of the bowel leading to small bowel obstruction. This most commonly occurs around the ileo-caecal valve.

➋ Air in the biliary tree (pneumobilia), and Dilated small bowel