Gallstones Flashcards by Eilidh Middleton

What is the laymans term for Cholelithiasis

Gallstones

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Where are Cholelithiasis i.e. gallstones formed?

Formed within the gallbladder or bile duct

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What is the function of the gallbladder

Stores and concentrates bile

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What secretes biles

Hepatocytes of the liver

Secretes bile into the biliary circulation

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What are the 3 components of bile

Bile pigments – product of haemoglobin metabolism

Phospholipid

Cholesterol

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Bile pigments is the product of _____ metabolism

Haemoglobin

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Define Acute cholecystitis

Inflammation of the gallbladder

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Define Acute cholangitis

inflammation of the biliary tree

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Gallstones are classified based on their consistency.

Name the 3 types of gallstones

Cholesterol stones

Pigment stones

Mixed stones

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Gallstones are classified based on their consistency: (1) Pigment; (2) Cholesterol; (3) Mixed

Describe the consistency of pigment stones

Composed purely of bile pigments

The result of excess bile pigments production

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Gallstones are classified based on their consistency: (1) Pigment; (2) Cholesterol; (3) Mixed

Describe the consistency of Cholesterol stones

Composed purely of cholesterol

Result of excess cholesterol production

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Gallstones are classified based on their consistency: (1) Pigment; (2) Cholesterol; (3) Mixed

Describe the consistency of mixed stones

Comprised of both cholesterol and bile pigments

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Name the three events that if one of them occurs gallstones are formed as a result

Cholesterol supersaturation

Biliary stasis

Increased secretion of bilirubin

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Name the 5 risk factors for gallstones

Five F’s mnemonic:

F – Female

F – Fair

F – Fertile

F – Forty

F – Fat

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What is the mainstay symptom of gallstones

Biliary colic - colicky pain in the RUQ

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What kind of jaudice is associated with gallstones

Obstructive jaundice (if the stone blocks the ducts)

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Obstruction of the biliary tree prevents bile from being secreted into the GI tract.

The result is

a) Pale or dark urine
b) Pale or dark stools

a) Dark urine
b) Pale stools

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What causes biliary colic

Caused by stones temporarily obstructing drainage of the gallbladder

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Biliary colic is caused by stones temporarily obstructing drainage of the gallbladder.

Where can the stones get stuck?

Lodged at the neck of the gallbladder or in the cystic duct

When the stone falls back into the gallbladder the symptoms resolve

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Describe the symptoms of biliary colic

Severe, colicky epigastric or right upper quadrant pain

Often triggered by meals (particularly high fat meals)

Lasting between 30 minutes and 8 hours

May be associated with nausea and vomiting

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Why do high fat meals stimulate biliary colic?

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum

CCK triggers contraction of the gallbladder, which can cause the stone to get lodged in the gallbladder neck causing biliary colic

Fat entering the digestive system causes secretion of which hormone from the duodenum

Cholecystokinin (CCK)

The complications of gallstones vary depending on the location of the gallstone.

What complications are associated with a gallstone in the gallbladder

Biliary colic

Acute cholecystitis

Gallbladder empyema (pus within the gallbladder)

The complications of gallstones vary depending on the location of the gallstone.

What complications are associated with a gallstone in the common bile duct

Obstructive jaundice

Acute cholangitis

Acute pancreatitis

The complications of gallstones vary depending on the location of the gallstone. What complications are associated with a gallstone in the **small intestine**

Gallbladder ileus (stone impacting the terminal ileum) causing small bowel obstruction

What is **Mirizzi Syndrome**

Gallstone in the Hartmanns pouch or in the cystic duct causing compression of the adjacent common hepatic duct. Result is obstructive jaundice.

What is **Gallbladder empyema**

Gallbladder has become filled with pus Often leading to sepsis. Similar clinical picture to acute cholecystitis

What are the symptoms of acute cholecystitis

Acute cholecystitis refers to inflammation of the gallbladder RUQ, fevers, malaise

What features will be present for acute cholecystitis on examination

Acute cholecystitis refers to inflammation of the gallbladder Tenderness Localised guarding may be present

What features will be present for acute cholecystitis on blood tests

Acute cholecystitis refers to inflammation of the gallbladder Raised inflammatory markers (WCC + CRP) Normal LFTs

What features will be present for acute cholecystitis on ultrasound

Acute cholecystitis refers to inflammation of the gallbladder Thickened wall of the gallbladder

What are the symptoms of acute cholangitis

acute cholangitis refers to inflammation of the biliary tree RUQ, fevers, malaise, confusion

What features will be present for acute cholangitis on examination

acute cholangitis refers to inflammation of the biliary tree Tenderness Jaundice

What features will be present for acute cholangitis on blood tests

acute cholangitis refers to inflammation of the biliary tree Raised inflammatory markers (CRP, WCC) Raised bilirubin, ALP and ALT

What are some of the features of acute cholangitis on ultrasound

acute cholangitis refers to inflammation of the biliary tree CBD stone (although USS sensitivity is low for these stones) Duct dilatation

What are the classical symptoms of acute pancreatitis

Acute pancreatitis refers to inflammation of the pancreas Epigastric pain radiating to the back

What is the key feature of acute pancreatitis on examination

Acute pancreatitis refers to inflammation of the pancreas Epigastric tenderness

What features will be present for acute pancreatitis on blood tests

**Raised amylase = pancreatitis**

What is the gold standard investigation for gallstones

Ultrasound

Ultrasound is the most sensitive initial imaging modality for gallstones. Name some of the limitations of ultrasound?

Ultrasound is limited by: Patient’s weight Gaseous bowel obstructing the view Discomfort from the probe

What is the imaging modality used for biliary tree disease

Biliary tree disease such as stones in the bile duct and malignancy Magnetic Resonance Cholangio-Pancreatography (MRCP) - MRI scan

Iif the ultrasound scan does not show stones in the duct, but there is bile duct dilatation or raised bilirubin. What is the diagnosis

Obstruction

Magnetic Resonance Cholangio-Pancreatography (MRCP) produces a detailed image of the biliary system. What kind of imaging modality is it: a) CT b) MRI c) X-ray d) Ultrasound

b) MRI

What is the main indication for Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

Clear stones in the bile ducts.

What is involved in Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

Involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the sphincter of Oddi Can inject contrast and take x-rays to visualise the biliary system and diagnose pathology e.g., stones or strictures Can perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow) Can clear stones from the ducts

Name the 3 potential complications of ERCP

Excessive bleeding Cholangitis (infection in the bile ducts) Pancreatitis

How do you manage asymptomatic patients with gallstones

Conservatively with no intervention required

How do you manage symptomatic patients or those with complications

Cholecystectomy

Define Cholecystectomy

Refers to the surgical removal of the gallbladder

Laparoscopic cholecystectomy (keyhole surgery) is preferred to open cholecystectomy (with a right subcostal “Kocher” incision). Why?

It has less complications and a faster recovery

Name some of the complications of cholecystectomy

Bleeding, infection, pain, and scars Damage to the bile duct including leakage and strictures Stones left in the bile duct Damage to the bowel, blood vessels or other organs Anaesthetic risks Venous thromboembolism (deep vein thrombosis or pulmonary embolism) Post-cholecystectomy syndrome

What is post-cholecystectomy syndrome

Refers to a group of non-specific symptoms that can occur after a cholecystectomy Symptoms often improve with time. Symptoms include: * Diarrhoea * Indigestion * Epigastric or right upper quadrant pain and discomfort * Nausea * Intolerance of fatty foods * Flatulence