Gallstones

Question 1

What are gallstones

Answer 1

Small stones that form in the gallbladder from concentrated bile. Most are made of cholesterol.

Question 2

Biliary system anatomy

Answer 2

Right and left hepatic duct join to form common hepatic duct.
Cystic duct from gall bladder joins with common hepatic duct to form common bile duct.
Pancreatic duct joins with common bile duct to become the ampulla of Vater.
The sphincter of Oddi is a ring of muscle surrounding ampulla of Vater that controls flow of bile and pancreatic secretions into the duodenum.

Question 3

What is cholestasis

Answer 3

Blockage to the flow of bile

Question 4

What is cholelithiasis

Answer 4

Gallstones are present

Question 5

What is choledocholithiasis

Answer 5

Gallstones in the bile duct

Question 6

What is biliary colic

Answer 6

Intermittent right upper quadrant pain caused by gallstones irritating bile ducts

Question 7

What is cholecystitis

Answer 7

Inflammation of gallbladder

Question 8

What is cholangitis

Answer 8

Inflammation of the bile ducts

Question 9

What is gallbladder empyema

Answer 9

Puss in the gallbladder

Question 10

What is a cholecystectomy

Answer 10

Surgical removal of gallbladder

Question 11

What is a cholecystostomy

Answer 11

Inserting a drain into gallbladder

Question 12

Risk factors for gallstones

Answer 12

4 F's:
Fat
Fair
Female
Forty

Question 13

Gallstones presentation

Answer 13

May be asymptomatic
Biliary colic - stones temporarily obstruct drainage of gallbladder and may get lodged in cystic duct.
Severe, colicky, epigastric or RUQ pain
Pain often triggered by meals (particularly high fat meals)
Last between 30mins to 8hrs
May have associated nausea and vomiting

Question 14

Pathophysiology behind biliary colic

Answer 14

Fat entering digestive system causes release of CCK from duodenum.
CCK triggers contraction of of gallbladder leading to biliary colic.

Question 15

Gallstones complications

Answer 15

Acute cholecystitis or cholangitis
Obstructive jaundice
Pancreatitis

Question 16

Gallstones investigations

Answer 16

Bloods - LFT’s, FBC, CRP, Amylase
USS - 1st line
MRCP - magnetic resonance cholangio-pancreatography
ERCP - endoscopic retrograde cholangio-pancreatography

Question 17

Gallstones LFT’s

Answer 17

Raised bilirubin (jaundice) with pale stools and dark urine represents an post-hepatic obstruction e.g. gallstone in CBD, cholangiocarcinoma, tumour of head of pancreas...
Raised ALP can indicate biliary obstruction in the presence of RIQ pain and/or jaundice. Can also be raised in pregnancy due to production by placenta or in bone/liver problems.
Raised ALT and AST (liver enzymes) can indicate hepatocellular injury

Question 18

Gallstones USS findings

Answer 18

Gallstones in either gallbladder or ducts
Bile duct dilation
Thickened gallbladder wall, stones or sludge and fluid around gallbladder can indicate acute cholecystitis

Question 19

How does ERCP work and what can you do with it

Answer 19

Endoscope passed into sphincter of Oddi.
Contrast can be injected to visualise biliary system on x-ray and diagnose pathology.
Sphincterotomy can be performed.
Clear stones from ducts.
Insert stents.
Take biopsies of tumours

Question 20

Complications of ERCP’s

Answer 20

Excessive bleeding
Cholangitis (infection in bile ducts)
Pancreatitis

Question 21

Gallstones management

Answer 21

ERCP

Cholecystectomy (removal of gallbladder) if symptoms or complications

Question 22

What does a cholecystectomy involve

Answer 22

Surgical removal of gallbladder.
Indicated when gallstones causing symptoms or complications.
Stones in bile ducts can be removed before by ERCP or in surgery.
Laparoscopic cholecystectomy preferred to open.

Question 23

Cholecystectomy complications

Answer 23

Bleeding, infection, pain, scars
Damage to bile duct including strictures or leakage
Stones left in bile duct
Damage to bowel, blood vessels or other organs
Anaesthetic risks
DVT or PE
Post-cholecystectomy syndrome

Question 24

What is post-cholecystectomy syndrome

Answer 24

Group of non-specific symptoms that can occur after a cholecystectomy. 
May be caused by changes in bile flow and often improve with time.
Diarrhoea
Indigestion 
Epigastric or RIQ pain or discomfort
Nausea
Intolerance to fatty foods
Flatulence