Gallstones

Question 1

Specific population of people with high incidence of gallstones.

Answer 1

Pima Indian Women

about 70% develop stones

Question 2

Most common type of gallstone.

Answer 2

Cholesterol stones (85%)

Question 3

Why are the elderly prone to cholesterol stones?

Answer 3

Cholesterol is converted to bile salts by 7-alpha-hydroxylase. This enzyme decreases with age and the lower activity leads to calculus formation.

Question 4

Main phospholipid that helps bile salts solubilize cholesterol.

Answer 4

Lecithin (95%)

Question 5

Name the two general mechanisms that lead to gallstone formation.

Answer 5

1. Excess cholesterol

2. Depleted bile salts

Question 6

Most important factor that leads to gallstone formation.

Answer 6

Gallbladder Stasis

Question 7

Which stones occur in a sterile environment and as a result of hemolysis pathology?

Answer 7

Black stones

-hemoglobinopathies, occur in GB

Question 8

Which stones occur due to infection and are most likely located in the bile ducts.

Answer 8

Brown Stones

Question 9

What is the Reynold Pentad?

Answer 9

Indicates emergent suppurative cholangitis.

Charcot Triad (RUQ pain, fever, jaundice) + shock + encephalopathy

Question 10

What is Mirizzi Syndrome?

Answer 10

When a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice.

Question 11

What is the treatment for acute cholescytitis?

Answer 11

Laparoscopic or Conventional cholecystectomy

Question 12

Name 4 treatments for Symptomatic Chronic Calculous Cholecystitis.

Answer 12

1. Surgery
2. Lithotripsy
3. Methyl tert-butyl ether (MTBE) dissolution: dissolves the stones but since it’s also used as a component in gasoline it has health risks.
4. UDCA (bile salt dissolution)

Question 13

Name 2 treatments for cholangitis.

Answer 13

1. ERCP

2. Cholecystectomy + bile duct exploration + T-tube

Question 14

Treatment for severe and mild/moderate Gallstone Pancreatitis.

Answer 14

Severe: ERCP w/ sphincterotomy and stone removal

M/M: ERCP or cholecystectomy

Question 15

Treatment for Mirizzi Syndrome

Answer 15

Cholecystectomy

Question 16

What is the major condition on a differential if a patient persists with RUQ pain even after a cholecystectomy?

Answer 16

Peptic Ulcer Disease

Question 17

Treatment of Sphincter of Oddi (choledochal sphincter) dysfunction.

Answer 17

ERCP w/ sphincterotomy

Question 18

How does a HIDA scan work?

Answer 18

Hepatobiliary Iminodiacetic Acid (HIDA) is an irradiated form of unconjugated bile that is taken up by the liver, conjugated and released into the biliary system. It will show up with nuclear imaging and can assess the function of the liver, gallbladder, and biliary tree.

AKA: cholescintigraphy

Question 19

Where do choledochal cysts form?

Answer 19

In the biliary tree, most commonly in the common bile duct.

Choledochal means biliary tree

Question 20

What is Caroli Syndrome?

Answer 20

Ectasia (dilation of vessels) of intrahepatic bile ducts linked with portal hypertension and congenital hepatic fibrosis.

Often patients also have renal cysts or hepatic stones.

Question 21

How effective is lithotripsy?

Answer 21

Very effective in breaking up the stones, however, the stones are not the primary problem. The gallbladder is the issue and the stones will often reappear so patients must be kept on UDCA to prevent relapse.

Question 22

Etiology and Tx for Biliary disease in pregnancy.

Answer 22

Caused by cholesterol supersaturation and gallbladder stasis.

Tx: Cholecystectomy in 2nd trimester or later
ERCP in 2nd or 3rd trimester

Radiation for CT Dx is fine once 2nd trimester is reached