Gallstones Flashcards
What are gallstones?
Gallstones (cholelithiasis) refers to the formation of hard stones in the gallbladder – a process which typically takes years to occur. It is a very common phenomenon which affects about 10-15% of the general population in the developed world.
What is the second most common organ that requires surgery in the GI tract?
Gallbladder
What does bile contain?
- Bile pigments (from Hb breakdown products)
- Cholesterol
- Other lipids
What are the 3 types of gallstones?
- Cholesterol stones
- Pigment stones
- Mix of both
75% of which type of gallstones are common in the USA and Europe?
Cholesterol
What are the clinical features of pure cholesterol stones?
- Usually solitary and large
- Risk factors = Female, age and obesity
Stones of about 70% or more of cholesterol are usually smaller and more numerous. The rest of the stone is made up of calcium compounds and protein.
What are the clinical features of mixed gallstones?
Usually multiple and irregular shaped
What two categorises can pigment stones be categorised into?
- Brown
- Black
What are brown mixed stones like?
Soft and contain a mixture of pigment, cholesterol and calcium salts
What are black mixed stones like?
Black stones are hard and made up of pure pigment
Why are females at greater risk of gallstones?
oestrogen and progesterone impair gallbladder emptying
What causes the formation of cholesterol and mixed stones? (2)
1) stasis
2) supersaturation of cholesterol
What are black pigment stones comprised of? (3)
1) polymerised calcium bilirubinate
2) calcium phosphate
3) calcium carbonate
Describe the appearance of black pigment stones (3):
1) small
2) hard
3) brittle
What causes the formation of black pigment gallstones? (2)
1) stasis
2) supersaturation of bilirubin
Give the five F risk factors for cholesterol stones:
1) female
2) forty plus
3) fair (white ethnicity)
4) fat
5) fertile
When do cholesterol stones form?
Cholesterol stones form when the concentration of micelles is not great enough to hold all the cholesterol in the micelles.
Patients with cholesterol stones generally have a smaller bile pool, which circulates more often.
What is cholesterol sludge?
Initially, cholesterol crystals will form in bile that is supersaturated with cholesterol. This results in the production of ‘sludge’
How is the formation of ‘sludge’ inhibited?
- Caffeine
- NSAIDs
- Bile salts
How is the formation of sludge exacerbated?
- Mucin
- Rapid weight loss
- pregnancy
- Increased serum cholesterol
- Reduced bile production
Which two types of gallstone cannot be seen on X-ray?
1) cholesterol stone
2) brown pigment stone
Give 5 conditions associated with the formation of black pigment gallstones:
1) sickle cell disease
2) thalassaemia
3) spherocytosis
4) malaria
5) hypersplenism
(all cause chronic haemolysis, leading to supersaturation of bilirubin)
Where do brown pigment stones commonly form?
in bile ducts (rather than the gallbladder itself)
Give three mild symptoms associated with uncomplicated gallstones:
1) upper abdominal pain
2) indigestion
3) nausea
What is cholestasis?
Blockage to the flow of bile
What is cholelithiasis?
Gallstones are present
What is Choledocholithiasis?
gallstone(s) in the bile duct
What is biliary colic?
intermittent right upper quadrant pain caused by gallstones irritating bile ducts
What is cholecystitis?
inflammation of the gallbladder
What is cholangitis?
inflammation of the bile ducts
What is gallbladder empyema?
Pus in the gallbladder
What is Cholecystectomy?
surgical removal of the gallbladder
What is Cholecystostomy?
inserting a drain into the gallbladder
What condition does gallstones typically present as?
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
What would you expect the LFTs to look like in someone with gallstones?
- Raised bilirubin (Obstruction to flow within the biliary system)
- Raised ALP - consistent with biliary obstruction
- Slightly raised ALT and AST, with a higher rise in ALP
What is the first-line investigation for gallstones?
Ultrasound
When is MRCP used to investigate gallstones?
MRCP is typically used to investigate further if the ultrasound scan does not show stones in the duct, but there is bile duct dilatation or raised bilirubin suggestive of obstruction.
When is an endoscopic retrograde cholangio-pancreatography (ERCP) indicated?
The main indication for ERCP is to clear stones in the bile ducts.
What is post-cholecystectomy syndrome?
Post-cholecystectomy syndrome involves 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.
What are the symptoms of post-cholecystectomy syndrome?
Diarrhoea
Indigestion
Epigastric or right upper quadrant pain and discomfort
Nausea
Intolerance of fatty foods
Flatulence
