Gallstones Flashcards
Bile has three major constituents
- Bile salts (primary-cholic and chenodeoxycholic acids; secondary- deoxycholic and lithocholic acids)
- phospholipids
- cholesterol
Bile containing excess cholesterol relative to bile salts and lecithin predisposes to gallstone formation
Types of gallstones
- Pure cholesterol (10%) - often solitary, large >2.5cm round
- pure pigment (bile salts) 10%
- Black (associated with haemolytic disease)
- brown (associated with chronic cholangitis and biliary parasites)
- mixed -80%
Common presentaitons
Bilary colic - intermittent severe epigastric and RUQ pain, usually associated with nausea and vomitting. Resolves after a few hours; tenderness over gall bladder during acute episodes
Acute cholecystitis - severe continuous RUQ pain; often radiates to right flank and back associated with anorexia and pyrexia. Tenderness over gall bladder during inspiration (Murphys sign)
chronic cholecystitis - repeated episode of infection causes thickening and fibrosis of gall bladder
Mucocele - stone in neck of gall bladder, bile is aborbes , but mucus secretion continues, prodccuing a large, tense, globural mass in the RUQ
Empyema - abscess of gall bladder
Investiagations
- FBC, U and Es, Blood culture, WCC increased, serum amylase - In acute
- utrasound - a thick-walled, shrunken GB, stones, CBD (dilated >6mm)
- HIDA cholescintigraphy (useful if diagnosis uncertain after ultrasoun)
- Plain AXR - only shows 10% of gallstones
Treatment
- Acute cholecystitis- NBM, pain relief, IVI, cefuroximine, Laprascopic cholecystectomy (acute or delayed) is the treatment of choice for all patiets fit for GA, open surgery is required if there is a GB eprforation. If high risk or elderly consider - percutaneous cholecystostomy, cholecystectomy
- Chronic cholecystitis - cholecystectomy, if US shows a dilated CBD with stones then ERCP + SPhincterotomy before surgery
- Bilary colic - Analgesia, rehydrate, NBM. Elective laparoscopic cholecystectomy
Common bile duct stones
- type as per gall bladder stones
- common bile duct stones present in 10% of patient with gallstones
- most pass from the gall bladder into the CBD
- rarely primary
Clinicopathologcal features of common bile duct stones
- asymptomatic- usually found incidentally on ultrasound for gall bladder stones
-
obstructive jaundice -
- usually due to CBD stone causing obstruciton; rarely due to stone induced CBD stricture
- anorexia, nausea, itch
- dark urine and pale stools
- epigastric pain and fever mroe common with CBS stones
- palpable distended gall bladder is rare
- Asceding cholangitis- constant severe right upper quandrant pain, obstructive jaindice and a high swinging fever (charcots triad)
- acute pancreatitis- sixty percent of acute pancreatitis in adults in the UK is due to gallstones
Investigations for CBD
Basic
- FBC (increased WCC in cholangitis and pancreatitis)
- U and E
- LFTS (increased in conjugated bilirubin and alkaline phosphatatse), serum amylase increased in pancreatitis)
- clotting studies
Advanced
- ultrasound - 1st line, acurracy low for distal CBD stone
- MRCP- use when inconclusive utlrasoun result
- ERCP - used diagnsotically for patients unable to tolerate MRCP (claustrophia), therapeutic interventions (stone extreaction and stent insertion)
Curvoisiers law
In the presence of jaundice, the gall bladder is palpable, then the cause of the jaundice in ulikely to be due to stone)
Due to the fact that CBD stones originate in the gall bladder which is usually scarred and fibrotic, preventing distention
Risk of ERCP
- haemorrhage
- acute pancreatitis
- ascending infection
- perforation
Treatment
Emergency
- indicated in unressolving gallstone pancreatitis, unresolving ascending cholangitis
- ERCP with stone extraction
Elective
- indicated for (all atient having had complications, and all patients with GB stones due for cholecystectomy)
- usually ERCP or combined ERCP/PTC
persistent after cholecystectomy
- Stones extracted via a T-Tube track if present (6 weeks after surgery)
