Gallstones Flashcards
Bile composition
water
bile acids/salts
bile pigments - biliverdin, bilirubin
cholesterol, fatty acids, phospholipids
electrolytes
What is the difference between a bile acid and a bile salt?
bile salt = bile acid that has been conjugated with glycine or taurine
Bile function
emulsification of fats
absorption of fats and fat-soluble vitamins (ADEK)
neutralised gastric secretions
excretion of substances such as bile pigments and excess cholesterol
laxative and lubrication for chyme
bacteriocidal
What is chyme?
the pulpy acidic fluid which passes from the stomach to the small intestine, consisting of gastric juices and partly digested food
Gallstones types
cholesterol stones
pigment stones
mixed stones
What causes a gallstone?
super saturation of bile
Which type of gallstone is common in haemolytic anaemia?
pigment stones
What increases the risk of cholesterol stones?
diet
obesity
Who gets gallstones?
5Fs:
- fat
- female
- fertile
- forty
- family history
Where can gallstones cause blockages?
in the gallbladder = cholelithiasis
in the biliary system = choledocholithiasis
outside the biliary system
Complications of gallstones
biliary colic
cholecystitis
Mirizzi’s syndrome
obstructive jaundice
ascending cholangitis
acute obstructive suppurative ascending cholangitis
panreatitis
gallstone ileus
Investigation + management of gallstones
full history + examination
initial investigations:
- FBC, U&Es, LFTs, CRP, amylase/lipase
- erect chest XR/abdo XR
- USS
initial management:
- analgesia
- IV fluids
- antibiotics
Gallstones symptoms
RUQ pain (after fatty food)
shoulder tip pain
nausea
fever
rigors
pale stools
dark urine
itching/pruritis
Signs of gallstones
RUQ tenderness
Murphy’s sign
pyrexia
icteric/jaundiced
tachycardia
aerobilia
Charcot’s triad
Reynold’s pentad
Courvoisier’s sign
Charcot’s triad
fever
RUQ pain
jaundice
(associated with cholangitis)
Reynold’s pentad
fever
abdo pain
jaundice
confusion
hypotension
(associated with obstructive ascending cholangitis)
Courvoisier’s sign
jaundice + painless enlarged gallbladder
What is biliary colic?
spasm of cystic ducts caused by calculi causing blockage
Biliary colic presentation, investigation + management
RUQ pain
bloods - normal
USS - gallstones, thin-walled gallbladder
analgesia
consider elective cholecystectomy
Define cholecystitis
when biliary colic progresses to inflammation/infection of the gallbladder
Murphy’s sign
acute cholecystitis
ask patient to take and hold deep breath while palpating right subcostal area
if pain occurs when inflamed gallbladder comes into contact with examiner’s hand, Murphy’s sign is positive
Cholecystitis presentation, investigation + management
RUQ pain
Murphy’s sign
fever
bloods - raised WBC/CRP, predominantly normal LFTs
USS - gallstones, thick-walled gallbladder
antibiotics
analgesia
consider ‘hot’ cholecystectomy
delayed cholecystectomy
cholecystostomy
What is Mirizzi syndrome?
common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
Mirizzi syndrome presentation, investigation, management
RUQ pain
Murphy’s sign
fever
jaundice
bloods - raised WBC/CRP, obstructive LFTs
USS - gallstones, thick-walled gallbladder, dilated intrahepatic ducts
MRCP
antibiotics
analgesia
complex surgical management
Obstructive jaundice presentation, investigations, management
jaundice
RUQ pain
Courvoisier’s Law = if gallbladder is palpable in jaundiced patient, it is unlikely due to gallstones
obstructive LFTs (high bilirubin, high ALP)
USS - dilated CBD +/- intrahepatic ducts
MRCP
management depends on cause
ERCP
cholecystectomy with common bile duct exploration
What is ascending cholangitis?
ascending bacterial infection of biliary tree
biliary stasis in obstructive jaundice leads to infection in biliary tree
Ascending cholangitis presentation, investigations, management
jaundice, RUQ pain, fever
Charcot’s triad
obstructive LFTs, raised WBC/CRP
USS - dilated common bile duct +/- intrahepatic ducts
MRCP
antibiotics
resuscitation
ERCP
What is suppurative cholangitis?
pus in bile ducts
Suppurative cholangitis presentation, investigations, management
jaundice
RUQ pain
fever
hypotension
mental obtundation
(Reynold’s pentad)
obstructive LFTs
raised WBC/CRP
USS - dilated common bile duct +/- intrahepatic ducts
MRCP
antibiotics
resuscitation
ERCP
?organ support
intensive care
How can gallstones cause pancreatitis?
temporary blockage of pancreatic duct
Pancreatitis presentation, investigation, management
epigastric pain
amylase >1000
USS - gallstones
CT abdomen/pelvis
supportive care
cholecystectomy
What causes gallstone ileus?
occurs in chronic cholecystitis where a gallstone erodes forming cholecystoenteric fistula (commonly into duodenum)
Gallstone ileus presentation, investigation, management
vomiting
constipation
hx of RUQ pain
may have normal bloods
XR/CT - aerobilia, bowel obstruction, may see gallstone at ICJ
CT abdomen/pelvis
NG tube
enterolithotomy
How does a gallstone look on USS?
high attenuation of gallstone
acoustic shadow behind
What is ERCP?
endoscopic retrograde cholangiopancreatography
How does gallstone ileus look on abdominal xray?
small bowel obstruction
aerobilia in RUQ
circular radio-opaque object in RIF
What is the most common cause of aerobilia?
previous ERCP with stricturotomy allowing air from GI tract to pass into biliary tree
What is aerobilia?
presence of air in biliary system
