Gallstones Flashcards
Differentials for epigastric pain, radiating to back, with vomiting, restlessness, 3 times in 12 months
- Biliary colic
- Acute cholecystitis
- Pancreatitis
- Gastroenteritis
- (Pneumonia)
- (Myocardial)
- because has similar symp/parasymp nerve distribution and thus experienced similarly by patient
List some relevant investigations for a presentation like in question 1
- UEC: Normal- dehydration, renal function, fit for surgery ^[these are general principles that apply beyond GIT]
- FBC: Normal- fit for surgery
- Lipase: Normal
- LFTs: Normal
- Upper abdominal ultrasound
- UEC, LFT should be normal in uncomplicated gallstones
- Lipase if suspect associated pancreatitis
- Coagulation studies if have liver disease
- Other blood tests as indicated per individual patient
- Imaging – ultrasound is the gold standard
Define cholecystitis
i.e. presence of stone + inflammation
In a minority of cases occurs in the absence of stones.
Describe the prevalence of stones
- Traditionally: 3F
- Female
- Fertile
- 40’s
- Overweight
- Developed countries
- Now younger; diet, diabetes
- Up to 15% population; symptomatic 8%
List the types of gallstones
- Cholesterol
- Pigment
- Mixed
cholelithiasis n. the presence of gallstones](http://127.0.0.1:5001/016_part7.xhtml#acref-9780198836629-e-3871) in the gall bladder ([cholecystolithiasis) or the common bile duct (*choledocholithiasis).
Describe cholesterol stones
- Most common: 80-90%
- Pure stones: Yellow-white and larger
- Mixed stones: More common, smaller, and multiple
- Black core of unconjugated bilirubin
List and describe the steps of cholesterol stone formation
- 3 principle conditions for stone formation:
- Cholesterol supersaturation
- Accelerated nucleation
- Gallbladder hypomotility
Cholesterol Supersaturation
- Ternary equilibrium phase diagram: represents ratio of cholesterol, phospholipids and bile salts that must be maintained otherwise stones will form
Accelerated Nucleation
- Hypersecretion & accumulation of mucin gel in the gallbladder lumen
- Ongoing immune-mediated inflammation - neutrophils
- research shows that WCCs or neutros constitutes the ‘glue’ holding the stones together
Gallbladder Hypomotility
- Patients with gallstones have increased fasting and residual gallbladder volumes
- Slower postprandial emptying
- Cholestasis, in pregnancy
What are risk factors for cholesterol stones?
- Family history
- Female gender
- Metabolic abnormalities: Insulin resistance, obesity, dyslipidemia & type II diabetes
- Crohn’s disease- due to loss of bile salts with diarrhoea
- Gastrointestinal bypass operations- same reason as Crohn’s
Describe pigment stones and types of pigment stones
- 10–25% of all stones
- More common in Asians
- Pigment from bilirubin precipitation; associated with high turnover of Hb eg in anaemia or leukaemia, as bilirubin is a byproduct of haem metabolism
Types of Pigment Stones
- Black Pigment Stones:
- Precipitate as calcium bilirubinate
- Associated with haemolysis, cirrhosis, and pancreatitis
- Brown Pigment Stones: - mixed stone
- Associated with biliary anaerobic infection
- Can form in the (gallbladder or) biliary tree
- East Asian association
List the complications of gallstones
- > 90% of people with gallstones are asymptomatic
- Asymptomatic → symptoms 1% per year cumulative
- Asymptomatic gallstones in general do not require surgical intervention; prophylactic cholecystectomy will be considered in type II diabetic patients with asymptomatic gallstones, especially if poorly controlled
- Biliary colic
- Cholecystitis
- Cholangitis
- Gallstone pancreatitis ^[most common pancreatitis in the community]
- Gallstone ileus and gallbladder cancer
describe biliary colic
- Spasm of the gallbladder due to stone stuck in the neck
- 30% have no further pain over 24 months
- Nearly 100% get further symptoms within 5 years
- Risk of serious complications needing surgery is 1–2% per year
- patient may complain for hours of pain eg after food, but not constant…
Describe acute cholecystitis
- Infection and inflammation of the gallbladder
- Constant epigastric pain associated with nausea, vomiting & fever
- Positive Murphy’s sign
- US, in addition to gallstone, wall thickness, para-cholecystic free fluid and positive sonographic Murphy’s sign
Describe acute cholecystitis management
-
Traditional Approach:
- Non-operative treatment + interval cholecystectomy
- Non-operative treatment: Analgesia, antibiotics, IV fluids & NBM
-
Current Consensus:
- Emergency laparoscopic cholecystectomy within 72 hours + non-operative treatment ^[as safe as elective, hence now it is standard care]
- eg for patients with worse outcomes eg T2DM patients
- Emergency laparoscopic cholecystectomy within 72 hours + non-operative treatment ^[as safe as elective, hence now it is standard care]
Describe cholangitis
- note: if stone has mobilised into tree eg CHD, CBD, at risk for cholangitis
- “Charcot’s triad”: Jaundice, epigastric pain & fever.
- Obstruction & infection in the biliary tree, SEPSIS, high mortality, emergency.
- Need IV antibiotics and urgent drainage
- ERCP, sphincterotomy, stone extraction, or insertion of CBD stent.
Describe gallstone pancreatitis
- Stone at the common channel of the common bile duct and pancreatic duct
- Abnormal LFTs & elevated pancreatic enzymes >3 times normal – lipase more reliable than amylase
- Epigastric pain, penetrating to the back, associated with **frequent vomiting
Describe gallstone pancreatitis management
- Non-operative treatment, gut rest, IV fluid, analgesia & IV antibiotics - get onto antibiotics immediately unless no clinical indication (imaging in this case eg CXR)
- Severity assessment, Clinically + imaging
- Cholecystectomy on the same admission as the risk of recurrence is about 20% in 1 month
- ERCP to remove stone, although 60% of stones are said to pass spontaneously
List some rarer long term complications of gallstones
- Senior patient / long history of gallstones
- Gallstone ileus: Gallstone passed into bowel via a cholecysto-enteral fistula causing bowel obstruction/small bowel
- Cancer of the gallbladder
Describe trans abdominal ultrasound
- Sensitivity 95% for stones >2mm in gallbladder
- 50% for stones in common bile duct-> do ERCP or MRCP instead
- Specificity 95% acoustic shadowing
- Advantages – portable, no ionizing radiation, no patient prep other than to fast
Normal Gallbladder
- Normal wall thickness
- No stones
- No shadowing
Chronic Cholecystitis
- Thickened gallbladder wall
- Multiple stones
- Acoustic shadows
List other imaging modalities
- Abdominal X-ray – see stones if calcified
- ERCP – expensive and invasive
- MRCP – gives a better view of the CBD
- Endoscopic Ultrasound – very good for lesions on the head of the pancreas
- HIDA scan – test of function, patency of the cystic duct. Nuclear medicine modality.
D
DEscribe uses of CT
- Good for assessing complications:
- Gallbladder perforation
- Abscess
- Post-operative collections
- Pericholecystic fluid
Describe ERCP
Endoscopic Retrograde Pancreatography (ERCP)
- Side-viewing endoscope
- Cuts sphincter to allow drainage of bile, extraction of stones
- Also diagnostic (as with MRCP eg see stone, remove stone, put in stent)
Descrieb operative cholangiogram
Operative Cholangiogram
- Filling of common bile duct
- Filling left and right hepatic ducts
- Flow into the duodenum
- Filling defects in bile ducts – stones or air bubbles (artifact)
Describe managment principles of gallstones
- Treat the patient
- Role of cholecystectomy
- Red flag for patients with:
- Cholecystitis + diabetes
- Cholangitis
- Gallstone pancreatitis
