Gallstones

Question 1

What does Bile contain?

Answer 1

cholesterol, phospholipids, bile salts, conjugated bilirubin and water

Question 2

What is the function of bile salts?

Answer 2

break down and emulsify fat in the intestine. it’s recycled enterohepatically and secreted once more into the bile

Question 3

Where does bile flow? What happens to bile in this destination?

Answer 3

flows into the gallbladder when the spincter of oddi is closed–> here it is concentrated as water is absorbed

Question 4

What does the gallbladder do?

Answer 4

fatty acids, amino acids in the duodenum cause secretion of CCK , which stimulates GB to secrete bile

Question 5

What is the process of gall stone formation called?

Who is it more common in?

Answer 5

cholelthiasis
incidence increases with age
10% 40+ yo women

Question 6

What are cholesterol gallstones? Factors causing it?

Answer 6

Cholesterol stones are caused by excessive cholesterol being secreted into the bile, or loss of bile salts.
Age, being female, multi-parity, pregnancy, OCP, obesity, diet, rapid weight loss, ileal disease, liver cirrhosis being factors

Question 7

What are bile pigment stones?

Answer 7

Bile stones: calcium bilirubinate
Either black (haemolytic disease) or brown (infection of biliary stasis), a common cause of recurrence

Question 8

What causes biliary colic or acute cholecystitis?

Answer 8

Impaction of a gallstone

Question 9

What is choledocholithiasis?

Answer 9

causes common bile duct obstruction
Obstructive jaundice and biliary colic.
Attacks last for hours-days, ceasing when the stone passes through the sphincter of Oddi or disimpacts and falls back into the dilated common duct. If the obstruction is not relieved, the chronic back pressure can lead to secondary biliary cirrhosis and liver failure.

Question 10

What is Mirizzi’s syndrome?

Answer 10

Extrinsic compression of common hepatic duct due to gallstone compacting the neck of the gallbladder or cystic duct
This leads to obstructive jaundice

Question 11

What is Gallstone ileus?

Answer 11

Uncommon condition where a large gallstone erodes through to the gall bladder lumen to create a fistula into the adjacent duodenum.
This can then produce an obstruction if it impacts in a narrow segment of bowel (usually the terminal ileum).
Characteristically on AXR there will be signs of small bowel obstruction, the gallstone may be visible and the will be air in the biliary tree (aerobilia).

Question 12

What is chronic cholecystitis?

Answer 12

recurrence of inflammation leads to fibrosis and gall bladder wall thickening
Recurrent bouts of abdominal pain due to mild cholecystitis. Discomfort and flatulence after fatty meals.

Question 13

Common cause of bile duct obstruction?

Answer 13

choledocholithiasis : Obstructive jaundice and biliary colic.
Attacks last for hours-days, ceasing when the stone passes through the sphincter of Oddi or disimpacts and falls back into the dilated common duct. If the obstruction is not relieved, the chronic back pressure can lead to secondary biliary cirrhosis and liver failure.

Question 14

What is ascending cholangitis ??

Answer 14

Infection of the common bile duct, which usually occurs following obstruction due to choledocholithiasis.

Question 15

What is Charcot’s triad?

Answer 15

RUQ, fever, jaundice
The duct system is severely inflamed, and the liver may be dotted with multiple small abscesses. These patients are very unwell and should be managed aggressively (10% mortality).

Question 16

Common tests and investigations to diagnose gallstones?

Answer 16

WBC / Inflammatory markers raised in cholecystitis.
LFTs may be marginally deranged in cholecystitis, significant derangement and obstructive jaundice type picture in common bile duct obstruction. Amylase to assess for pancreatitis (often mildly elevated in gallstone disease, large elevations in acute stone-related pancreatitis).
Prothrombin time (pre-intervention, likely increased).

First line imaging; abdo Uss
o Will show stones in gall bladder (echogenic foci & acoustic shadow). o Thickened gall bladder wall of acute/ chronic inflammation.
o Increased diameter of the common bile duct in obstruction.

MRCP
Can visualize the biliary tree and detect any calculi.

Question 17

Management: asymptomatic gallstones found incidentally

Answer 17

choleocystectomy if patient at risk with significant co-morbidities

Question 18

Management: biliary colic

Answer 18

bed rest, fluids and analgesia (NBM)
Elective laparoscopic cholecystectomy;
Medical treatments involve giving bile salts orally (chenodeoxycholic acid) for small, non-calcified stones in a minority of patients unfit for surgery.

Question 19

Management:: acute cholecystitis

Answer 19

bed rest, fluids and analgesia (NBM)
Elective laparoscopic cholecystectomy;
Medical treatments involve giving bile salts orally (chenodeoxycholic acid) for small, non-calcified stones in a minority of patients unfit for surgery.

As above with IV cefuroxime.
The most commonly cultured organisms are E.Coli, Klebsiella & Streptococcus.

Question 20

Management: chronic cholecystitis

Answer 20

Laparoscopic cholecystectomy, with cholangiogram to ensure no stones
remain in the common bile duct (if so, removed at ERCP).

Question 21

Management: obstructive jaundice due to stones

Answer 21

ERCP for sphincterotomy and to remove the stones using a balloon or Dormia basket, as an emergency if there is a high fever.
Any intervention is preceded with IV vitamin K, as a lack of bile salts mean this may not have been absorbed well.
Elective laparoscopic cholecystectomy.

Question 22

Management: ascending cholangitis?

Answer 22

Sepsis six bundle, with IV cefuroxime + metronidazole & emergency ERCP.

Sepsis six:
IV fluids
Oxygen
IV antibiotics
Blood culture
Urine output hourly
Lactate

Question 23

Presenting symptoms of carcinoma of GB? treatment and survival?

Answer 23

Uncommon adenocarcinoma that occurs in the elderly, associated with long- standing gallstones.
There is direct invasion of the liver as well as lymphatic spread.
Symptoms resemble chronic cholecystitis;
o RUQ pain.
o Nausea/vomiting.
o Weight loss.
o Finally obstructive jaundice and a palpable mass.
Treatment is surgical, with radical cholecystectomy +/- liver resection if caught incidentally, although most tumours present too late for surgical therapy (survival is short).

Question 24

Presenting symptoms of chonlangiocarcinoma? treatment and survival?

Answer 24

Adenocarcinoma arising from the epithelium of the bile duct/ ampulla. Common sites are at the confluence of the ducts in the biliary tree.
Present as painless progressive jaundice, as with cancer of the head of the pancreas.
They can also arise from intrahepatic ducts, in which case they and present like HCC.
More likely to occur in primary sclerosing cholangitis (and IBD).
They are slow growing and metastasise late, but are often advanced at presentation with low long-term survival.
Extra-hepatic or periampullary tumours may be treated by curative resection (Whipple’s procedure).
Palliative stenting (ERCP) may be used in advanced disease.