Gallstones Flashcards
RF ?
F – Fat
F – Fair
F – Female
F – Forty
Presentation?
Biliary colic caused by stones temporarily obstructing drainage of the gallbladder.
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
Complications?
Acute cholecystitis
Acute cholangitis
Obstructive jaundice (if the stone blocks the ducts)
Pancreatitis
Diagnosis? (LFTs)
Bilirubin- Raised bilirubin (jaundice) with pale stools and dark urine represents an obstruction to flow within the biliary system.
Alkaline Phosphatase (ALP) is a non-specific marker. A raised ALP is consistent with biliary obstruction in presence of right upper quadrant pain and/or jaundice.
Raised alkaline phosphatase can also be caused by liver or bone malignancy, primary biliary cirrhosis, Paget’s disease of the bone and many other things.
Aminotransferases (ALT) and aspartate aminotransferase (AST) are enzymes produced in the liver. They are helpful as markers of hepatocellular injury
In patients with cholestasis (e.g., due to gallstones), ALT and AST can increase slightly, with a higher rise in ALP (“an obstructive picture”).
If ALT and AST are high compared with the ALP level, this is more indicative of a problem inside the liver with hepatocellular injury (“a hepatitic picture”).
Diagnosis (clinical)?
Ultrasound Findings
Gallstones in the gallbladder
Gallstones in the ducts
Bile duct dilatation (normally less than 6mm diameter)
Acute cholecystitis (thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder)
The pancreas and pancreatic duct
-MRCP if the ultrasound scan does not show stones in the duct, but there is bile duct dilatation or raised bilirubin suggestive of obstruction.
-ERCP. An endoscopic retrograde cholangio-pancreatography (ERCP) involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system.
The main indication for ERCP is to clear stones in the bile ducts.
ERCP allows the operator to:
Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures)
Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow)
Clear stones from the ducts
Insert stents to improve bile duct drainage (e.g., with strictures or tumours)
Take biopsies of tumours
Key complications of ERCP are:
Excessive bleeding
Cholangitis (infection in the bile ducts)
Pancreatitis
CT scans?
CT scans are less useful for looking at the biliary system and for gallstones. They may be used to look for differential diagnoses (e.g., pancreatic head tumour) and complications such as perforation and abscesses.
How does a cholecystectomy work?
surgical removal of the gallbladder. When patients are symptomatic leading to complications (e.g., acute cholecystitis). Stones in the bile ducts can be removed before (by ERCP) or during surgery.
Laparoscopic cholecystectomy (keyhole surgery) is preferred to open cholecystectomy (with a right subcostal “Kocher” incision), as it has less complications and a faster recovery.
Complications of cholesystectomy?
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?
a group of non-specific symptoms that can occur after a cholecystectomy. They may be attributed to changes in the bile flow after removal of the gallbladder. Symptoms often improve with time. Symptoms include:
Diarrhoea
Indigestion
Epigastric or right upper quadrant pain and discomfort
Nausea
Intolerance of fatty foods
Flatulence
