Gallstones

Question 1

Define Biliary Colic

Answer 1

Intermittent right upper quadrant pain caused by gallstones irritating bile ducts

Question 2

Define Cholecystitis

Answer 2

Inflammation of the gallbladder

Question 3

Define cholangitis?

Answer 3

Infection and obstruction of the biliary system

Question 4

What is the difference between cholecystectomy and cholecystostomy?

Answer 4

Cholecystectomy: Surgical removal of the gallbladder
Cholecystostomy: inserting a drain into the gallbladder

Question 5

What are the four RF for Gallstones?

Answer 5

Fat
Fair
Female
Forty

Question 6

What is the first step in investigating gallstones?

Answer 6

Liver function tests and ultrasound
Indicated for investigating symptoms of gallstone disease (i.e. abdominal / right upper quadrant pain, jaundice)
Ultrasound is the most sensitive initial test for gallstones (CT scans are not good at identifying gallstones/biliary disease)
Ultrasound is limited by the patient’s weight, gaseous bowel obstructing the view and patients discomfort with probe.

Question 7

What is the second step in investigating gallstones?

Answer 7

MRCP (Magnetic Resonance Cholangio-Pancreatography)
Indicated if USS doesn’t show ductal stones but the is bile duct dilitation or raised bilirubin
An MRI scan that produces detailed image of the biliary system
Very sensitive and specific for biliary tree diseases (e.g. ductal stones / malignancy)

Question 8

What is the 3rd step in investigating gallstones?

Answer 8

ERPC (Endoscopic Retrograde Cholangio-Pancreatography)
Indicated for established CBD stones / obstructing ductal tumours on USS or MRCP
An endoscopy (via mouth) down to the sphincter of Oddi (CBD opening)
Allows for treatment of CBD stones / stricture dilitation / biopsy of malignant areas

Question 9

What is the 4th step in the investigation/management process for gallstones?

Answer 9

Cholecystectomy
Indicated where symptomatic / problematic gallbladder stones are established in a patient fit for surgery
Removal of the gallbladder
If stone/s in the bile ducts, they must be removed prior to cholecystectomy

Question 10

What are the acute USS findings in gallstones?

Answer 10

Acute cholecystitis: thickened gallbladder wall, stones / sludge in gallbladder and fluid around the gallbladder
Gallstones in the gallbladder
Gallstones in the ducts
Bile Duct Dilatation (Upper limit of normal is 6mm plus 1mm for every decade after 60)

Question 11

What LFTs come back in gallstone disease?

Answer 11

Raised bilirubin (jaundice)
Represents an obstruction to flow along the bile duct
May be gallstone in the bile duct or an obstructing mass (e.g. cholangiocarcinoma / head of pancreas tumour)

Raised Alkaline Phosphatase (ALP)
Non-specific marker
Consistent with cholestasis in presence of RUQ pain and/or jaundice
Can also be cause by liver or bone metastasis, primary biliary cirrhosis, Paget’s disease or many other things

Raised aminotransferase
(ALT/AST)
Markers or hepatocellular injury
Expect a slight rise in obstructive jaundice but if very high vs ALP more indicative of hepatocellular process
Consider a full liver screen if rise greater than ALP

Question 12

Describe acute cholecystitis?

Answer 12

Murphy’s sign:
RUQ tenderness exacerbated by deep inspiration
Place hand in RUQ and apply pressure
Ask patient to take deep breath in
Gallbladder will move downwards under your hand and cause pain
Inflammation of the wall of the gallbladder
Majority caused by gallstones (calculous cholecystitis)
Minority have other causes e.g. injury during surgery or septicaemia (acalculous cholecystitis)
Treatment with fasting, fluids, antibiotics (if evidence of infection) and eventual laparoscopic cholecystectomy

Question 13

What is gallbladder empyema and how is it treated?

Answer 13

Infected tissue and pus in gallbladder

Treatment by cholecystectomy: inserting a drain into the gallbladder to drain an gallbladder empyema

Question 14

Describe acute cholangitis?

Answer 14

Infection Biliary Obstruction
Diagnosis based on Charcot’s triad: Right Upper Quadrant Pain, Fever, Jaundice
High mortality due to sepsis / septicaemia
Requires antibiotics, treatment of sepsis and mechanical intervention
Mechanical intervention to relieve obstruction
ERCP
PTC (see below)

Question 15

Describe what is involved in an ERCP procedure?

Answer 15

Colangio-Pancreatography: retrograde injection of contrast into duct through sphincter of Oddi and xray images to visualize biliary system

Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal

Stone removal: a basket can be inserted and pulled through the CBD to remove stones

Balloon dilatation: a balloon can be inserted and inflated to treat strictures

Biliary stenting: a stent can be inserted to maintain a patent bile duct (if strictures or tumours)

Biopsy: a small biopsy can be taken to diagnose obstructing lesions

Question 16

What complications can be caused by ERCP?

Answer 16

Notable complications: bleeding, pancreatitis, infection.

Question 17

What is Percutaneous Transhepatic Cholangiography (PTC)?

Answer 17

Percutaneous Transhepatic Cholangiography (PTC)
Involves radiologically guided insertion of a needle / drain through the skin and liver into the bile ducts
Contrast can be injected into the biliary system to get xray images to visualize the system
Internal bile duct stents can be inserted to relieve strictures
An external drain can be left in to allow bile to drain externally and bypass a biliary obstruction

Question 18

Describe a cholecystectomy

Answer 18

Removal of the gallbladder
Offered to people with symptomatic / problematic gallstones
Most frequently done laparoscopically unless difficult procedure
Day case procedure
Not usually done “hot” – usually wait 6 weeks or so after cholecystitis for inflammation to reduced prior to removing
Notable complications: chronic diarrhoea