GALLSTONES

Question 1

What does bile consist of?

Answer 1

Water
Bile acids
Cholesterol
Bilirubin

Question 2

Which group tends to get gallstones?

Answer 2

Overweight caucasian women - especially those who then lose quiet a lot of weight rapidly

Question 3

What percentage of gall stones are symptomatic?

Answer 3

10-20%

Question 4

Where must the blockage be to cause jaundice?

Answer 4

At least as far as the common bile duct.

Question 5

What might a blockage in the common bile duct cause?

Answer 5

Jaundice
Cholestasis
Cholangitis
Pancreatitis

Question 6

What are 80% of the stones in the UK made from?

Answer 6

They are cholesterol stones with small amounts of calcium salts and bilirubin.

Question 7

What do stones normally look like?

Answer 7

Smooth with a yellow surface

Question 8

What are black pigment stones?

Answer 8

Sterile bile composed of Ca bilirubinate, inorganic Ca salts, mucin glycoprotein.

Question 9

What are brown pigment stones?

Answer 9

Infected bile along with the salts involved in black pigment stones (cholangitis)

Question 10

What is the difference between cholelithiasis and choledocholithiasis?

Answer 10

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

Question 11

What is cholecystitis?

Answer 11

Inflammation of the gallbladder, most commonly due to blockage of the cystic duct by a gallstone.

Question 12

What are the signs and symptoms of cholecystitis or symptomatic choledocholithiasis?

Answer 12

Biliary colic (referred right upper quadrant pain) especially after ingestion of fatty foods
Fever
Nausea
Vomiting
Murphy's sign
Jaundice (actually rare)

Question 13

What is Murphy’s sign?

Answer 13

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.

Question 14

What investigations might you order in someone with suspected cholecystitis or symptomatic choledocholithiasis?

Answer 14

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

Question 15

What might the FBC of someone with cholecystitis or symptomatic choledocholithiasis show?

Answer 15

High neutrophils

Question 16

What might the LFTs of someone with cholecystitis or symptomatic choledocholithiasis show?

Answer 16

Features of cholestasis:

Raised bilirubin
ALP
Check amylase isn’t overly raised to exclude acute pancreatitis

Question 17

What does a hydroxy imino-diacetic acid (HIDA) scan show you?

Answer 17

Shows function of the gallbladder and will demonstrate any blockages in cystic or common bile duct by its delay in bile excretion.

Question 18

When might you use ERCP in someone with suspected gallstones?

Answer 18

Used when therapy is required (stone removal, stent insertion), but also shows blockage in common bile duct.

Question 19

Why might MRCP be preferable to ERCP?

Answer 19

No risk of pancreatitis.

Question 20

Why might ERCP be preferable to MRCP?

Answer 20

If therapy is needed.

Question 21

Why are patients with terminal ileal disease at increased risk of developing gallstones?

Answer 21

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.

Question 22

What are the complications associated with biliary tree obstruction?

Answer 22

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

Question 23

How are patients with symptomatic gallstones managed?

Answer 23

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)