Gallstones

Question 1

Define cholelithiasis, biliary colic, choledocholithiasis, cholecystitis and cholangitis

Answer 1

Cholelithiasis = Presence of solid concretions on the gallbladder

Biliary colic = pain due to gallstone temporarily blocking the bile duct

Choledocholithiasis = presence of solid secretions in the common bile duct

Cholecystitis = pain + fever

Cholangitis = Pain + fever + jaundice

Question 2

Aetiology of gallstones

Answer 2

Made of:
Cholesterol (90%)
Pigment (5-10%) e.g. black, brown
Calcium
Bilirubin
Mixed

Bile supersaturation with cholesterol due to liver secreting excess amounts of cholesterol
Accelerated nucleation aids precipitation of cholesterol microcrystals
Gallbladder hypomotility facilitates retention to provide time for microcrystals to agglomerate in a mucin scaffold → gallstones

Question 3

Risk factors for gallstones

Answer 3

Cholesterol stones: obesity, TPN, rapid weight loss, medications e.g. oestrogen, ocreotide, cefs
Black pigment stones: chronic haemolytic anaemia, cirrhosis, cystic fibrosis, ileal disease
Brown pigment stones: stasis (partial obstruction) and infection (bacterial, parasites)
Age (>40)
Obesity, DM and metabolic syndrome
Female sex and hormones (2-3x), pregnancy
Gene mutations
NALD
Prolonged fasting/rapid weight loss e.g. after surgery
Haemoglobinopathy
Crohn’s

Question 4

Symptoms of gallstones

Answer 4

Asymptomatic in 80%

RUQ/epigastric pain
- Lasts >30 minutes
-Constant pain which increases in intensity
-Responds to analgesia
-Post-prandial (typically 1 hour)
Dyspepsia, heartburn, flatulence, bloating
Nausea
Jaundice (uncommon, unless Mirizzi syndrome*)

Mirizzi syndrome = gallstone is lodged in the neck of gallbladder, causing compression of the common bile or hepatic duct

Question 5

Signs of gallstones on examination

Answer 5

RUQ/Epigastric tenderness
Murphy’s: respiratory arrest upon deep inspiration on palpation of the biliary fossa (cholecystitis

Question 6

Investigations for gallstones

Answer 6

LFTs: normal OR raised ALP/GGT
FBC: elevated in cholecystitis/cholangitis
Lipase/amylase: exclude pancreatitis

US abdomen: presence of stone/dilatation
MRCP: if US has not detected stones
EUS: stones
Abdominal CT: exclude differentials

Question 7

Management for cholelithiasis

Answer 7

Symptomatic:
Analgesia e.g. paracetamol/diclofenac
± anti-spasmodic e.g. hycosine IV/IM
Laparoscopic cholecystectomy

Asymptomatic: observation

Question 8

Management for choledocholithiasis

Answer 8

Analgesia e.g. paracetamol/diclofenac
± anti-spasmodic e.g. hycosine IV/IM

Bile duct clearance via ERCP with biliary sphincterotomy and stone extraction

or

laparoscopic common bile duct exploration at the same time as laparoscopic cholecystectomy

Question 9

Complications of treatment for gallstones

Answer 9

ERCP-associated pancreatitis
Bile duct injury (iatrogenic)
Post-sphincterotomy bleeding

Question 10

Complications of gallstones

Answer 10

3% are at increased risk of complications: acute cholecystitis, cholangitis, or acute pancreatitis
In patients with asymptomatic stones, 0.1% to 0.3% will experience a major complication per year
Acute cholecystitis, cholangitis
Acute biliary pancreatitis
Mirizzi syndrome

Gallstone ileus → Rigler’s triad
1. small bowel obstruction
2. pneumobilia (air in the biliary tree, arising from the cholecysto- duodenal fistula)
3. ectopic gallstones as seen on abdominal X-ray, US or CT

Question 11

Prognosis for gallstones

Answer 11

Favourable for those managed by cholecystectomy or ERCP
Risk factors for recurrent choledochal problems are common with: bile duct dilatation to >15 mm; a periampullary diverticulum; brown pigment stones; or the gallbladder being left intact