Gallstones

Question 1

where in the biliary tract can gallstones occur?

Answer 1

• gallbladder
• common bile duct
• pancreatic duct
• hepatic duct

Question 2

what is acute cholecystitis most commonly caused by?

Answer 2

gallstones

Question 3

what is jaundice?

Answer 3

the accumulation of excess bile pigments in the tissues secondary to abnormally elevated serum bilirubin levels

Question 4

what is acute cholangitis most commonly caused by?

Answer 4

an acute bacterial infection within the biliary tree

Question 5

what is chronic cholecystitis?

Answer 5

chronic inflammation of the gallbladder caused by repeated episodes of gallbladder irritation, often due to gallstones

Question 6

what are the factors that trigger the formation of gallstones?

Answer 6

• supersaturation
• stasis
• sepsis

Question 7

what is cholestasis caused by?

Answer 7

• obstruction (e.g. stricture, tumour)
• impairment of flow (e.g. oestrogen, progesterone)
• surgery (e.g. vagus nerve injury, reduced cholecystokinin secretion)

Question 8

which anaerobic bacteria possess enzymes that deconjugate bilirubin and produce a bile pigment sludge?

Answer 8

• e. coli
• klebsiella
• enterobacter

Question 9

what are the different types of gallstones?

Answer 9

• cholesterol
• black pigment
• brown pigment

Question 10

what are cholesterol stones caused by?

Answer 10

stasis + supersaturation of cholesterol

Question 11

what are the risk factors for cholesterol stones?

Answer 11

five ‘F’-s

• female
• forty
• fair
• fat
• fertile

Question 12

what are black pigment stones caused by?

Answer 12

stasis + supersaturation of bilirubin

Question 13

which conditions are associated with the formation of black pigment stones?

Answer 13

• haemolysis (e.g. sickle cell disease, thalassaemia)
• gilbert’s syndrome
• cirrhosis
• chronic pancreatitis

Question 14

what are brown pigment stones caused by?

Answer 14

chronic bacterial infection

Question 15

what is obstructive jaundice caused by?

Answer 15

a blockage of bile drainage through the biliary system, which may occur from the intrahepatic duct branches to the ampulla of vater

Question 16

what is the role of the gallbladder?

Answer 16

to concentrate and store bile produced by the liver + release it when required

Question 17

what is bile?

Answer 17

• a dark green alkaline fluid which contains water, bilirubin, bile acids, cholesterol, phospholipids and electrolytes
• it neutralises gastric acid and emulsifies fats to facilitate their digestion and absorption

Question 18

what causes bile to be released from the gallbladder?

Answer 18

• enteroendocrine I-cells release cholecystokinin when fatty foods enter the duodenum
• this stimulates the contraction of the gallbladder + the relaxation of the sphincter of oddi

Question 19

what are the risk factors for gallstones?

Answer 19

• age
• female
• obesity
• high-fat diet
• rapid weight loss
• fasting
• impairment of bile flow (e.g. cirrhosis, PSC, obstetric cholestasis)

Question 20

what are the symptoms of uncomplicated gallstones?

Answer 20

• intermittent upper abdominal pain
• indigestion
• nausea
• bloating
• excessive flatulence
• intolerance of fatty foods
• altered bowel habit

Question 21

what are the acute complications of a gallstone becoming stuck in the gallbladder neck or cystic duct?

Answer 21

• biliary colic
• acute cholecystitis
• mirizzi syndrome

Question 22

what are the chronic complications of a gallstone becoming stuck in the gallbladder neck or cystic duct?

Answer 22

• gallbladder mucocele
• chronic cholecystitis
• porcelain gallbladder
• gallbladder cancer

Question 23

what are the acute complications of a gallstone becoming stuck in the common bile duct?

Answer 23

• obstructive jaundice
• acute cholangitis
• gallstone pancreatitis

Question 24

what are the chronic complications of a gallstone becoming stuck in the common bile duct?

Answer 24

cholangiocarcinoma

Question 25

what are the symptoms of biliary colic?

Answer 25

- severe, sudden pain in the RUQ - nausea + vomiting - sweating - palpitations

Question 26

what is biliary colic triggered by?

Answer 26

by eating fatty or spicy foods, with the pain starting a few hours afterwards or waking the patient up overnight

Question 27

what are the symptoms of acute cholecystitis?

Answer 27

- normally begins as an attack of biliary colic, but the pain lasts more than 6 hours and worsens - the pain is exacerbated by movement - pain radiating to the right shoulder is much more common as the local inflammatory process also irritates the phrenic nerve - patients usually feel systemically unwell with vomiting + fevers

Question 28

what are the features of acute cholecystitis on examination?

Answer 28

- pyrexia - tachycardia - severe pain in the RUQ - voluntary guarding / localised peritonism - murphy's sign

Question 29

what is murphy's sign?

Answer 29

- a painful inspiratory 'catch' during RUQ palpation - when the patient takes a deep breath in, their tender inflamed gallbladder bumps into the examiner’s hand, causing them to jump or flinch

Question 30

what are the symptoms of obstructive jaundice?

Answer 30

- yellowing of the skin + sclera - dark urine - pale stool - pruritus

Question 31

what is charcot's triad, and what is it associated with?

Answer 31

- pain in the RUQ - jaundice - fever - ? rigors - acute cholangitis

Question 32

what are the investigations for biliary colic?

Answer 32

US

Question 33

what are the investigations for acute cholecystitis?

Answer 33

- FBC - LFTs - CRP + ESR - US - ? CT

Question 34

what imaging is used to assess a gallstone in the common bile duct?

Answer 34

magnetic resonance cholangiopancreatography (MRCP)

Question 35

what is the management of biliary colic?

Answer 35

elective laparoscopic cholecystectomy

Question 36

what is the management of acute cholecystitis?

Answer 36

- antibiotic - emergency laparoscopic cholecystectomy - ? percutaneous cholecystostomy

Question 37

how should a blockage of the common bile duct by a gallstone be managed?

Answer 37

- urgent endoscopic retrograde cholangiopancreatography (ERCP) + stone extraction followed by laparoscopic cholecystectomy - urgent laparoscopic cholecystectomy with common bile duct exploration (CBDE) + intraoperative stone extraction

Question 38

what is the management for ascending cholangitis?

Answer 38

- IV fluid - IV broad-spectrum antibiotic - ? ICU - ERCP / percutaneous transhepatic cholangiography and biliary drainage (PTC / PTBD)

Question 39

what are the long-term complications of cholelithiasis?

Answer 39

- cholecystitis - pancreatitis - gallbladder empyema - peritonitis - obstructive jaundice - mirizzi syndrome - ascending cholangitis - gallbladder mucocele - porcelain gallbladder - cholangiocarcinoma

Question 40

what are the complications of acute cholecystitis?

Answer 40

- gangrenous cholecystitis - gallbladder empyema - emphysematous cholecystitis