Gallstones Flashcards by Helena Angel-Scott

Who is most likely to get gallstones

Fair

Fat

Fertile

Female

Family history

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What are the common varieties of gallstones

Cholesterol stones - 20%

Bile pigment stones - 5% (black pigment stones)

Mixed stones - 75% (brown pigment stones)

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What may cholesterol stones be associated with

High cholesterol

Pregnancy

Diabetes

Oral contraceptive pill

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What is the pathophysiology of a cholesterol stone

Bile salts and phospholipids hold insoluble cholesterol in suspension

Decrease of either can lead to cholesterol gallstones

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What are bile pigment stones

Small, black, irregular, multiple, gritty and fragile stones

Occur in excess of circulating bile pigment (eg. haemolytic anaemia)

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What are mixed stones

A mixture of cholesterol, bile pigments and calcium salts

Cholesterol is the predominant constituent

They are multiple and faceted

They originate because of precipitation of cholesterol

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What are some predisposing factors for gallstones

Excess mucus production by the gallbladder

Infection of the biliary tract

Metabolic factors

Stasis (eg. in pregnancy)

Ileal dysfunction (prevents reabsorption of bile)

Obesity

Chronic liver disease

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What are some of the pathological effects of gallstones

Asymptomatic - 20%

Obstruction of the gallbladder

Movement of a stone into the common bile duct

Ulceration of a stone through the wall of the gallbladder - gallstones may erode into the duodenum or colon. May cause gallstone ileus

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How can gallstones cause obstruction of the gallbladder

A gallstone may become impacted in Hartmann’s pouch, causing an obstruction to the exit of the gallbladder

Tihs causes cholecystitis

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What is gallstone ileus

Impaction of a stone in the distal ileum resulting in intestinal obstruction

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In gallstone ileus, where in the GI tract does the gallstone normally become lodged

At the level of the ileocaecal valve OR

at the site of Meckel’s diverticulum

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Where is Meckel’s diverticulum

2 feet proximal to the ileocaecal valve

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How can gallstones present

Biliary colic

Acute cholecystitis

Chronic cholecystitis

Gallstone pancreatitis

Obstructive jaundice

Acute cholangitis

Gallstone ileus

Empyema and emphysema of the gallbladder

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What is biliary colic

It probably results from distension of the gallbladder outlet or duct system when a stone becomes impacted

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What are the features of biliary colic

Colicky right hypochondrial/epigastric pain

Pain radiating to lower pole of right scapula

Restless and rolling in agony

Sweaty, nauseous and vomiting

*The episode may resolve when the stone is passed along the duct or falls back into the gallbladder

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What are some differentials for biliary colic

Renal colic

Intestinal obstruction

Angina

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What is acute cholecystitis

Inflammation of the gallbladder

In 95% cases it is secondary to obstruction of the cystic duct by gallstones

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What are the typical clinical features of acute cholecystitis

RUQ pain - becoming more severe, constant and localised after 1/2 days

Fever

Rigors

History of previous dyspepsia, fat intolerance, or biliary colic

On examination

Guarding in the RUQ
Murphy’s sign
Palpable mass - if gallbladder is distended

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What is Murphy’s sign

Patient catches breath on inspiration while the right hypochondrium is deeply palpated (specifically the approximate location of the gallbladder).

Due to downward movement of the inflamed gallbladder onto the examining hand during inspiration

Does not occur on deep palpation of the left hypochondrium

Where is the approximate location of the gallbladder on surface anatomy

Below the costal margin on the right side at the mid-clavicular line

What are some complications of acute cholecytitis

Empyema of gallbladder

Perforation of the gallbladder causing peritonitis

Obstructive jaundice

What are some causes of acalculous acute cholecystitis

(inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction)

If a single causative stone has passed

Typhoid fever

In critically ill individuals

*5% cases

What are some differentials for acute cholecystitis

Perforated duodenal ulcer

Acute pancreatitis

Right-sided basal pneumonia

Acute appendicitis

What is chronic cholecystitis

Almost always associated with gallstones that repeatedly inflame the gallbladder

This results in fibrosis and thickening of the entire gallbladder wall

How does a patient with chronic cholecystitis present

Longstanding symptoms of dyspepsia with episodes of cholecystitis

What are some differentials for chronic cholecystitis

Peptic ulceration Hiatus hernia Angina

What is gallstone pancreatitis

Transient blocking of the ampulla of Vater by passing stones can trigger acute pancreatitis

What is Courvoisier's law

In the presence of a large non-tender gallbladder that is associated with jaundice, the cause is unlikely to be gallstones

What is acute cholangitis

Due to infection of the bile in the biliary tree It develops in the presence of bile duct obstruction and biliary infection Charcot's triad is present It should also be suspected in any patient with biliary obstruction who develops septicaemia

What is Charcot's triad

RUQ pain Fever Jaundice

What factors predispose to acute cholangitis

Stones in the common bile duct Biliary stricture Post-biliary reconstructive procedures Post-bile duct instrumentation (eg. ERCP)

How does a patient with gallstone ileus present

History of RUQ pain Acute small-bowel obstruction

How do you treat a patient with a gallstone ileus

Resuscitation Nasogastric decompression Urgent laparotomy * Gallstone should be milked back up the terminal ileum to a healthy bit of bowel and then removed Definitive treatment of the fistula should be left until the acute attack has settled

What is empyema of the gallbladder

Severe form of acute cholecystitis Occurs mainly in elderly Pus in the gallbladder Patients are very septic Early surgery prevents perforation

What is emphysematous cholecystitis

Presents in elderly or immunocompromised As a result of gangrenous gallbladder infected with gas forming bacteria Urgent surgery is required

What bacteria causes emphysematous cholecystitis

Clostridium perfringens

What are the mainstays for diagnosis of gallbladder disease

US LFTs MRCP/ERCP

How do you manage acute cholecystitis

Non-surgical: * Admission to hospital * Pain relief with opiates * IV fluids * Broad spectrum antibiotics Surgical: * Elective cholecystectomy - either during admission or 6 weeks after discharge

Why is cholecystectomy receommended after an attack of cholecystitis

High risk of recurrent attacks High risk of life threatening complications in future attacks * Perforation of the gallbladder * Pancreatitis * Obstructive jaundice

What is the non-surgical management of gallstones

Low fat diet Oral bile salts (eg. chenodeoxycholic acid) used to dissolve small, non-calcified stones in patients unfit for surgery

What are the disadvantages to non-surgical management of gallstones

Prolonged treatment for months Attacks of biliary colic as fragments of stone are passed Recurrence (common)

What incision is used for an open cholecystectomy

Kocher's - right subcostal

What are some complications of a cholecystectomy

Haemorrhage from slipped tie or from gallbladder bed Biliary leak Biliary stricture from damage to biliary tree

What are some contraindications to laparoscopic cholecystectomy

Jaundice Cirrhosis Previous upper abdo surgery Surgeon not familiar with equipment or technique Acute cholecystitis Morbid obesity Pregnancy

In which cases is ERCP less likely to be successful as a therapeutic option

Aberrant diverticulum Periampullary diverticulum Prior upper GI surgery Difficult stones * Those that are over 15mm * Intrahepatic * Impacted * Multiple Stricture associated with the stone