Gallstones

Question 1

Describe the anatomy of the biliary system

Answer 1

Question 2

What sphincter controls the outflow of bile and pancreatic secretions?

Answer 2

The sphincter of Oddi - ring of muscle surrounding the ampulla of Vater

Question 3

List 4 risk factors for gallstones (5Fs)

Answer 3

Fat, female, fertile forty and fair

Question 4

How do gallstones present?

Answer 4

1. Asymptomatic OR
2. Severe, colicky epigastric or RUQ pain +/- nausea and vomiting OR
3. With complications

Question 5

List 3 complications of gallstones

Answer 5

1. Acute cholecystitis
2. Acute cholangitis
3. Obstructive jaundice (if stone blocks the ducts)
4. Pancreatitis

Question 6

Describe the typical presentation of a gall stones

Answer 6

Severe, colicky epigastric or RUQ pain, may be associated with nausea and vomiting

Question 7

What causes the symptoms of biliary colic

Answer 7

Stones temporarily obstructing drainage of the gallbladder, at the neck or in the cystic duct

Question 8

How long do symptoms of biliary colic tends to last

Answer 8

30 minutes to 8 hours

Question 9

Name a common trigger for biliary colic

Answer 9

Meals, especially high in fat

Question 10

Why may patients diagnosed with gallstones be advised to avoid high fat meals?

Answer 10

1. Fats entering GIT cause CCK secretion from duodenum
2. CCK triggers gallbladder contraction → biliary colic
3. Avoiding fatty foods prevents CCK release and gallbladder contraction

Question 11

List 3 potential causes of raised bilirubin (jaundice) with pale stools and dark urine

Answer 11

Obstructive picture

1. gallstones in bile duct
2. cholangiocarcinoma
3. tumour of the head of the pancreas

Question 12

Is a raise in alkaline phosphatase specific?

Answer 12

No, may be raised in pregnancy, liver or in bone disease

If ↑ALP + RUQ pain +/- jaundice, diagnosis is consistent with biliary obstruction

Question 13

List 4 conditions which cause a raise in ALP

Answer 13

1. Biliary obstruction
2. Liver or bone malignancy
3. Primary biliary cirrhosis
4. Paget’s disease of the bone

Question 14

Compare the raise in liver enzymes seen in an obstruction vs hepatic injury picture

Answer 14

Higher ALP compared to AST and ALT → obstructive picture

Higher ALT and AST compared to ALP level → hepatitic picture

Question 15

First line investigation for gallstones?

Answer 15

Ultrasound scan

Question 16

List 4 findings on USS indicative of gallstones

Answer 16

1. Gallstones in the gallbladder
2. Gallstones in the ducts
3. Bile duct dilatation
4. Acute cholecystitis
5. The pancreas and pancreatic duct

Question 17

List 2 limitations of USS for gallstones

Answer 17

1. weight
2. gaseous bowel obstructing the view
3. discomfort from the probe

Question 18

Next line investigation if USS does not show stones but there is still high clinical suspicion?

Answer 18

MRCP

Question 19

How are stones removed from the duct?

Answer 19

ERCP

(Removal of stones is the main indication for ERCP)

Question 20

List 4 indications for ERCP

Answer 20

1. Stone removal and visualisation of the biliary tree
2. Sphincterotomy
3. Stent insertion (eg. with strictures or tumours)
4. Biopsies of tumours

Question 21

List 4 key complications of ERCP

Answer 21

1. Excessive bleeding
2. Duodenal perforation
3. Cholangitis
4. Pancreatitis

Question 22

Management of asymptomatic gallstones

Answer 22

Conservatively, no intervention required

Question 23

Management of symptomatic gallstones or complications?

Answer 23

Laparoscopic cholecystectomy

Question 24

Why may a patient experience jaundice following a cholecystectomy?

Answer 24

Gallstones in the CBD (choledocholithiasis) at the time of cholecystectomy, can result in obstructive jaundice