Gallstones

Question 0

What are the constituents of bile?

Answer 0

92% water
Bile salts/acids
Bile pigment (bilirubin, biliverdin)
Cholesterol
Inorganic compounds

Question 1

What are the different types of gallstones?

Answer 1

Mixed stones make up 75-90%
Cholesterol stones
Pigment stones (calcium bilirubinate)
Calcium carbonate stones

Question 2

Describe the biliary tree.

Answer 2

Bile canalculi beside the hepatocytes join to form the left and right hepatic ducts which becomes the common hepatic duct. This joins the cystic duct to become the common bile duct which joins with the pancreatic duct forming the ampulla of vater.

Question 3

What structure prevents duodenal reflux into the bilary tree?

Answer 3

Sphincter of Oddi

Question 4

Describe the characteristics of Pigment Stones (4)

Answer 4

Numerous, jet black, 0.5-1cm, uniform size

Question 5

What is the pathogenisis of Mixed Gallstones? (3)

Answer 5

Abnormalities of bile constituents
Bile Stasis
Infection

Question 6

What are the fat-solvable vitamins?

Answer 6

Vitimins A,D,E and K

Question 7

What hormone is released from endocrine cells in the duodenal mucosa to stimulate gallbladder contractions?

Answer 7

Cholecystokinin-pancreozymin

Question 8

Where is Bile reabsorbed?

Answer 8

Terminal Ileus

Question 9

The Coeliac Trunk divides into which arteries?

Answer 9

Left gastric
Splenic
Hepatic

Question 10

What does the Porta Hepatis consist of?

Answer 10

Portal Vein
Extrahepatic Bile Ducts
Hepatic Arteries

Question 11

What usually forms the core on which bile stones are built?

Answer 11

Bacteria

Question 12

What is the result of unresolved obstruction of the cystic duct?

Answer 12

A mucocoele which is palpable and tender

This can become an empyema if infected

Question 13

Gall bladders commonly show a Chronically Obstructed histological pattern. What are the features of this? (4)

Answer 13

Atrophied Mucosa
Submucosal and subserosal fibrosis
Hypertrophy of the muscular wall
Diverticula extending into the muscular layer (Rokitansky-Aschoff sinuses)

Question 15

What is chronic inflammation of the Gallbladder called when there is no evidence of a stone on cholecystectomy?

Answer 15

Cholecystitis sans stones

Question 16

What is the cause and definition of bilary colic?

Answer 16

Transient obstruction by a stone causing acute pain

Question 17

What is the cause and definition of acute cholecystitis?

Answer 17

Prolonged obstruction by stone leading to chemically inflamed tissue.

Question 18

How would a patient with acute cholecystitis differ from a patient with bilary colic clinically?

Answer 18

A patient with acute cholecystitis would appear systemically unwell with tachycardia and a fever.

Question 19

What is the normal diameter of the bile ducts?

Answer 19

0.6cm

Question 20

What are the aims of investigations into a patient with gallstone symptoms? (3)

Answer 20

To rule out haematological or hepatic causes
To establish if there is a stone and its location
To assess the bile ducts for suggestion of dilation or tumours

Question 21

Name 3 common haemolytic disorders which may need rules out by blood tests in gall stones

Answer 21

Hereditary spherocytosis
Sickle cell anaemia
Thalassaemias

Question 22

What investigation is most commonly carried out in a patient with suspected gallstones?

Answer 22

Ultrasonography

Question 23

What two things are most commonly demonstrated pathologically with ultrasound?

Answer 23

Thickening of the gallbladder wall (due to inflammation or fibrosis)
Dilitation of the common duct system

Question 24

Which are stones often not directly visualised by ultrasonography?

Answer 24

They are often obstructed by gas in the duodenum

Question 25

What other investigations can be employed to assess gallstone disease?

Answer 25

ERCP
MRCP
Endoscopic sphincterotomy

Question 26

What is the mnemonic for the ‘typical’ gallstone patient? (5)

Answer 26

Fair, fat, female, fertile and forty

Question 27

What is raynauds pentad and what disease is it associated with?

Answer 27

Jaundice
Fever 
RUQ pain
Shock
Confusion 

Ascending cholangitis