Gallstones

Question 1

Define Cholecystolithiasis

Answer 1

Gallstone in gallbladder

Question 2

Define Choledocholithiasis

Answer 2

Gallstone in common bile duct

Question 3

What is the prevalence & patient demographics?

Answer 3

Common: 5-30% in western countries mainly fat females & elderly

Question 4

What are the types of gallstones?

Answer 4

1. Cholesterol
2. Pigment
3. CaCO3
4. Mixed stones
5. PO42-
6. Ca steatrate stones
7. Protein stones
8. Cystine stones
   In order of incidence

Question 5

What is the pathophysiology?

Answer 5

Imbalance in chemical composition of bile which results in precipitation of one or more of the constituents

Question 6

Causes?

Answer 6

Infection
Stasis- partial biliary obstruction (brown pigment)
High Cholesterol: 1) Bile supersaturated w/cholesterol, 2) accelerated nucleation, 3) gallbladder hypermotility retaining abnormal bile

Question 7

Risk factors?

Answer 7

Obesity
Age
Female
Serum triglycerides
Low HDL
Weight cycling (bulk-cut), rapid weight loss after bariatric surgery
DM
Drugs: HRT, ceftriaxone, oestrogen
Smoking
Crohn’s
Genetic/ethnic

Question 8

Clinical presentation?

Answer 8

80% asymptomatic
Biliary colic is most common presentation:
-Upper abdomen/right upper quadrant, postprandial
->30 minutes but <8 hours
-Colicky in nature
-Severe
-Associated: nausea and vomiting
-No fever or abdo tenderness.
Acute cholecystitis: Above plus fever & tenderness
Obstructive jaundice

Question 9

Signs

Answer 9

Murphy’s sign: patient inhales while the examiner’s fingers are hooked under the liver. Inspiration causes the gallbladder to descend onto the fingers, producing pain if inflamed.
Charcot triad: Ascending cholangitis: fever, jaundice, RUQ pain

Question 10

Differentials?

Answer 10

Peptic ulcer
Gastritis
IBS
GORD
Pancreatitis
Tumours
Acute hepatitis
IBD
Bile duct stricture

Question 11

Investigations

Answer 11

Abdo USS
Bloods: FBC, LFTs, serum lipase & amylase
(Even if both are done, does not rule out gallstone disease as cause of symptoms)
Consider: MRCP (magnetic resonance cholangiopancreatography) if USS not detected CBD stones but bile duct is dilated or LFTs abnormal.
Endoscopic ultrasound
ERCP (endoscopic retrograde cholangiopancreatography)

Question 12

Management

Answer 12

• Observe: Asymptomatic
• Cholecystectomy: symptomatic, recurrent
• Surgical admission: for systemically unwell with suspected complications, ERCP, lithotripsy, laparoscopic CBD exploration
• Refer:biliary colic + symptoms + US of gallstones
• Pain relief: parenteral analgesic for rapid relief of severe pain e.g. diclofenac 75mg IM or opioid IM if diclofenac not suitable. NSAID for intermittent pain.
• Avoid food or drinks triggers
• Cholecystostomy: placement of catheter through abdo wall to drain contents of blocked gallbladder

Question 13

Complications

Answer 13

Biliary colic. Pain caused by gallbladder, cystic duct, or common bile duct (CBD) contracting around a stone
Obstructive jaundice
Acute cholecystitis: inflammation/ infection f gallbladder
Gallstone pancreatitis
Cholangitis: inflammation/ infection of CBD
Fistula
Gallbaldder mucocele
gallbladder Ca

Question 14

Prognosis

Answer 14

Most asymptomatic.
2-4% develop complications
Uncomplicated biliary colic is unpleasant but not life-threatening.
Acute pancreatitis and cholangitis are life threatening