GALLSTONES Flashcards
What does bile consist of?
Water
Bile acids
Cholesterol
Bilirubin
Which group tends to get gallstones?
Overweight caucasian women - especially those who then lose quiet a lot of weight rapidly
What percentage of gall stones are symptomatic?
10-20%
Where must the blockage be to cause jaundice?
At least as far as the common bile duct.
What might a blockage in the common bile duct cause?
Jaundice
Cholestasis
Cholangitis
Pancreatitis
What are 80% of the stones in the UK made from?
They are cholesterol stones with small amounts of calcium salts and bilirubin.
What do stones normally look like?
Smooth with a yellow surface
What are black pigment stones?
Sterile bile composed of Ca bilirubinate, inorganic Ca salts, mucin glycoprotein.
What are brown pigment stones?
Infected bile along with the salts involved in black pigment stones (cholangitis)
What is the difference between cholelithiasis and choledocholithiasis?
Cholelithiasis is the presence of gall stones in the gall bladder
Choledocholithiasis is the clinical scenario where the gallstones pass into the cystic or common bile ducts
What is cholecystitis?
Inflammation of the gallbladder, most commonly due to blockage of the cystic duct by a gallstone.
What are the signs and symptoms of cholecystitis or symptomatic choledocholithiasis?
Biliary colic (referred right upper quadrant pain) especially after ingestion of fatty foods Fever Nausea Vomiting Murphy's sign Jaundice (actually rare)
What is Murphy’s sign?
Place hand in right upper quadrant and ask patient to breathe in. If they have pain as the gall bladder catches on hand then sign is positive. Can only be considered positive if repeating the procedure on the left hand side elicits no pain.
What investigations might you order in someone with suspected cholecystitis or symptomatic choledocholithiasis?
FBC
LFTs
Abdominal X-ray - not routine because most are not radio opaque
Ultrasound - sensitive for detection of gallstones in bladder but not diagnostic
Radioisotope scan (HIDA scan)
ERCP
MRCP
What might the FBC of someone with cholecystitis or symptomatic choledocholithiasis show?
High neutrophils
What might the LFTs of someone with cholecystitis or symptomatic choledocholithiasis show?
Features of cholestasis:
Raised bilirubin
ALP
Check amylase isn’t overly raised to exclude acute pancreatitis
What does a hydroxy imino-diacetic acid (HIDA) scan show you?
Shows function of the gallbladder and will demonstrate any blockages in cystic or common bile duct by its delay in bile excretion.
When might you use ERCP in someone with suspected gallstones?
Used when therapy is required (stone removal, stent insertion), but also shows blockage in common bile duct.
Why might MRCP be preferable to ERCP?
No risk of pancreatitis.
Why might ERCP be preferable to MRCP?
If therapy is needed.
Why are patients with terminal ileal disease at increased risk of developing gallstones?
Terminal ileum is responsible for bile salt reabsorption. Malfunction leads to a reduction of bile salts in the liver. Consequently there is reduced micelle production and hence precipitation of cholesterol. This increases formation of cholesterol stones.
What are the complications associated with biliary tree obstruction?
Septicaemia
Peritonitis
Acute pancreatitis - swelling or obstruction at the ampulla of Vater secondary to gallstones in the common bile duct
Ascending cholangitis - infection in common bile duct spreading into intra-hepatic ducts
Gallstone ileus - large stone in the narrowed ileum
Carcinoma of the gall bladder
How are patients with symptomatic gallstones managed?
If there are signs of infection:
Analgesia and antiemetics
IV fluids
Blood cultures followed by broad spectrum antibiotics
Cholecystectomy is mainstay once infection has resolved.
ERCP for those who are unsuitable for surgery.
Chenodeoxylate and ursodeoxycolic acid are bile acids that can be taken orally and increase cholesterol solubility in bile. (Rarely used as treatment)
