Gallstones Flashcards
What are gallstones
Small stones that form in the gallbladder from concentrated bile. Most are made of cholesterol.
Biliary system anatomy
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.
What is cholestasis
Blockage to the flow of bile
What is cholelithiasis
Gallstones are present
What is choledocholithiasis
Gallstones in the bile duct
What is biliary colic
Intermittent right upper quadrant pain caused by gallstones irritating bile ducts
What is cholecystitis
Inflammation of gallbladder
What is cholangitis
Inflammation of the bile ducts
What is gallbladder empyema
Puss in the gallbladder
What is a cholecystectomy
Surgical removal of gallbladder
What is a cholecystostomy
Inserting a drain into gallbladder
Risk factors for gallstones
4 F's: Fat Fair Female Forty
Gallstones presentation
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
Pathophysiology behind biliary colic
Fat entering digestive system causes release of CCK from duodenum.
CCK triggers contraction of of gallbladder leading to biliary colic.
Gallstones complications
Acute cholecystitis or cholangitis
Obstructive jaundice
Pancreatitis
Gallstones investigations
Bloods - LFT’s, FBC, CRP, Amylase
USS - 1st line
MRCP - magnetic resonance cholangio-pancreatography
ERCP - endoscopic retrograde cholangio-pancreatography
Gallstones LFT’s
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
Gallstones USS findings
Gallstones in either gallbladder or ducts
Bile duct dilation
Thickened gallbladder wall, stones or sludge and fluid around gallbladder can indicate acute cholecystitis
How does ERCP work and what can you do with it
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
Complications of ERCP’s
Excessive bleeding
Cholangitis (infection in bile ducts)
Pancreatitis
Gallstones management
ERCP
Cholecystectomy (removal of gallbladder) if symptoms or complications
What does a cholecystectomy involve
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.
Cholecystectomy complications
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
What is post-cholecystectomy syndrome
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
