Gallstones

Question 1

What is the general composition of gallstones?

Answer 1

• Phospholipids
• Bile pigments
• Cholesterol

Question 2

Describe cholesterol gallstones?

Answer 2

• Large, often solitary
• Formation increased according to Admirand’s triangle
  
  • Low bile salts and lecithin
  • High cholesterol

Question 3

Risk factors for gall stones?

Answer 3

• Fat, female, fertile, forty, family history
• Pregnancy, oral contraceptives, haemolytic anaemia, malabsorption

Question 4

Describe pigment gallstones?

Answer 4

• Small, black, gritty fragile
• Calcium bilirubinate
• Associated with haemolysis

Question 5

Describe mixed gallstones?

Answer 5

• Often multiple
• Cholesterol is the major component

Question 6

Complications of gallstoens in the gall bladder?

Answer 6

1. Bilary colic
2. Acute cholecystitis +/- empyema
3. Chronic cholecystitis
4. Mucocele
5. Carcinoma
6. Mirizzi’s syndrome

Question 7

Complications of gallstones in the common bile duct?

Answer 7

1. Obstructive jaundice
2. Pancreatitis
3. Cholangitis

Question 8

Complications of gallstoens in the gut?

Answer 8

Gallstone ileus

Question 9

Describe Bilary colic?

Answer 9

• Gallbladder spasm against a stone impact in the neck of the gallbladder
  
  • Hartmanns pouch
• Stone may also be in the common bile duct
• (biliary colic is the pain not a disease)

Question 10

Presentation of biliary colic?

Answer 10

• RUQ pain radiating to the back
• Associated with sweating, pallor/N/V

Question 11

Differentials for biliary colic?

Answer 11

• Cholecystitis / other gallstone disease
• Pancreatitis
• Bowel perforation

Question 12

Investigations for biliary colic?

Answer 12

• Urine: bilirubin, urobilinogen, Hb
• Bloods: FBC, U&Es, amylase, LFTs, clotthing, CRP
• Imaging:
  
  • AXR: 10% of gallstones are radio-opaque
  • CXR: signs of perforation
  • US: if dilated ducts => MRCP

Question 13

Treatment for biliary colic?

Answer 13

• Conservative
  
  • Rehydrate
  • Opiod analgesia
• Surgical
  
  • Urgent lap chole
  • Elective lap chole (6-12 weeks)

Question 14

Describe the pathogenesis of Acute cholecystitis?

Answer 14

• Stone or sludge impact in Hartmann’s pouch
  
  • => chemical / bacterial inflammation
• Acalculus causes:
  
  • sepsis, burns, DM

Question 15

Sequelae from Acute cholecystitis?

Answer 15

1. Resolution +/- recurrence
2. Gangrene
3. Chronic cholecystitis
4. Empyema

Question 16

Describe the presentation of acute cholecystitis?

Answer 16

• Severe RUQ pain
  
  • Continuous
  • Radiates to right. scapula and epigastrium
• Fever
• Vomiting

Question 17

Clinical signs of Acute cholecystitis?

Answer 17

• Local peritonism in RUQ
• Tachycardia with shallow breathing
• Murphey’s sign
• Phlegmon may be palpable
• Boas’ sign
  
  • Hyperaesthesia below the right scapula

Question 18

Investigations into Acute cholecystitis?

Answer 18

• Urine: bilirubin, urobilinogen
• Bloods:
  
  • Raised white cells
  • U&Es: dehydration from vomiting
  • Amylase, LFTs, clotting, CRP
• US:
  
  • Stones: acoustic shadow
  • Dilated ducts (>6cm)
  • Inflamed gallbladder

Question 19

What investigation can be done after US to confirm a acute cholecystitis diagnosis?

Answer 19

• HIDA cholescintigraphy
  
  • Shows failure of gall bladder filling
• MRCP if dilated ducts seen on US

Question 20

Describe the management of Acute cholecystitis?

Answer 20

• ​Fluids, analgesia
• IV antibiotics: ceftriazone, metronidazole
• Cholecystectomy within 1 week
• Empyema
  
  • Percutaneous drainage

Question 21

Describe Chronic cholecystitis?

Answer 21

• Repeated bouts of colic/cholecystitis
• Fibrosis, gallbladder contraction and thickening of the gall bladder wall
• Gall bladder ceases to function

Question 22

Describe the symptoms of Chronic cholecystitis?

Answer 22

• Vague upper abdominal discomfort
• Distension, bloating
• Flatulence, burping
• Symptoms exacerbated by fatty foods

Question 23

Differentials for chronic cholecystitis?

Answer 23

• PUD
• IBS
• Chronic pancreatitis

Question 24

Investigations for Chronic cholecystitis?

Answer 24

• US:
  
  • stones, fibrotic, shrunken, gallbladder
• MRCP

Question 25

Treatment for Chronic cholecystitis?

Answer 25

• Medical
  
  • Bile salts
• Surgical
  
  • Elective cholecystectomy
  • ERCP first if US shows dilated ducts and stones

Question 26

Describe a Mucocele?

Answer 26

• Neck of gallbladder blocked by stone but contents remains sterile
• Can be large enough to palpate
• Can lead to empyema

Question 27

Describe a Gallbladder carcinoma?

Answer 27

• Associated with gallstones and gallbladder polyps
• Calcification of gallbladder -> porcelain gallbladder

Question 28

Describe Mirizzi’s syndrome?

Answer 28

• Large stone in gallbladder presses on the common hepatic duct
  
  • Obstructive jaundice
• Stone may erode through into the ducts

Question 29

Describe Gallstone ileus?

Answer 29

• Large stone erodes from gallbladder into duodenum
  
  • Through cholecysto-duodenal fistula
• Rigler’s triad:
  
  • Pneumobilia
  • Small bowel obstruction
  • Gallstones in RLQ

Question 30

Treatment for Gallstone ileus?

Answer 30

Stone removal through enterotomy

Question 31

Features of obstructive jaundice?

Answer 31

• Jaundice
• Pale stools
• Dark urine

Question 32

Describe Courvoisier’s law?

Answer 32

• If the gallbladder is palpable in the presence of jaundice, the jaundice is unlikely to be due to gall stones
• Think of a malignant cause

Question 33

Describe important components of an Open cholecystectomy?

Answer 33

• Right subcostal incision
• Injury to bile duct is main source of morbidity

Question 34

What bacteria can cause wound infection following cholecystectomy?

Answer 34

• Organisms present in bile
  
  • E. coli
  • Klebsiella aerogenes
  • Strep. faecalis

Question 35

Describe postcholecestectomy syndrome?

Answer 35

• Postprandial flatulence, fat intolerance, epigastric/right hypochondrial pain
• More severe when cholecystectomy has been performed in absence of gallstones