Gallstones Flashcards
What is the general composition of gallstones?
- Phospholipids
- Bile pigments
- Cholesterol
Describe cholesterol gallstones?
- Large, often solitary
- Formation increased according to Admirand’s triangle
- Low bile salts and lecithin
- High cholesterol
Risk factors for gall stones?
- Fat, female, fertile, forty, family history
- Pregnancy, oral contraceptives, haemolytic anaemia, malabsorption
Describe pigment gallstones?
- Small, black, gritty fragile
- Calcium bilirubinate
- Associated with haemolysis
Describe mixed gallstones?
- Often multiple
- Cholesterol is the major component
Complications of gallstoens in the gall bladder?
- Bilary colic
- Acute cholecystitis +/- empyema
- Chronic cholecystitis
- Mucocele
- Carcinoma
- Mirizzi’s syndrome
Complications of gallstones in the common bile duct?
- Obstructive jaundice
- Pancreatitis
- Cholangitis
Complications of gallstoens in the gut?
Gallstone ileus
Describe Bilary colic?
- 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)
Presentation of biliary colic?
- RUQ pain radiating to the back
- Associated with sweating, pallor/N/V
Differentials for biliary colic?
- Cholecystitis / other gallstone disease
- Pancreatitis
- Bowel perforation
Investigations for biliary colic?
- 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
Treatment for biliary colic?
- Conservative
- Rehydrate
- Opiod analgesia
- Surgical
- Urgent lap chole
- Elective lap chole (6-12 weeks)
Describe the pathogenesis of Acute cholecystitis?
- Stone or sludge impact in Hartmann’s pouch
- => chemical / bacterial inflammation
- Acalculus causes:
- sepsis, burns, DM
Sequelae from Acute cholecystitis?
- Resolution +/- recurrence
- Gangrene
- Chronic cholecystitis
- Empyema
Describe the presentation of acute cholecystitis?
- Severe RUQ pain
- Continuous
- Radiates to right. scapula and epigastrium
- Fever
- Vomiting
Clinical signs of Acute cholecystitis?
- Local peritonism in RUQ
- Tachycardia with shallow breathing
- Murphey’s sign
- Phlegmon may be palpable
- Boas’ sign
- Hyperaesthesia below the right scapula
Investigations into Acute cholecystitis?
- 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
What investigation can be done after US to confirm a acute cholecystitis diagnosis?
- HIDA cholescintigraphy
- Shows failure of gall bladder filling
- MRCP if dilated ducts seen on US
Describe the management of Acute cholecystitis?
- Fluids, analgesia
- IV antibiotics: ceftriazone, metronidazole
- Cholecystectomy within 1 week
- Empyema
- Percutaneous drainage
Describe Chronic cholecystitis?
- Repeated bouts of colic/cholecystitis
- Fibrosis, gallbladder contraction and thickening of the gall bladder wall
- Gall bladder ceases to function
Describe the symptoms of Chronic cholecystitis?
- Vague upper abdominal discomfort
- Distension, bloating
- Flatulence, burping
- Symptoms exacerbated by fatty foods
Differentials for chronic cholecystitis?
- PUD
- IBS
- Chronic pancreatitis
Investigations for Chronic cholecystitis?
- US:
- stones, fibrotic, shrunken, gallbladder
- MRCP
Treatment for Chronic cholecystitis?
- Medical
- Bile salts
- Surgical
- Elective cholecystectomy
- ERCP first if US shows dilated ducts and stones
Describe a Mucocele?
- Neck of gallbladder blocked by stone but contents remains sterile
- Can be large enough to palpate
- Can lead to empyema
Describe a Gallbladder carcinoma?
- Associated with gallstones and gallbladder polyps
- Calcification of gallbladder -> porcelain gallbladder
Describe Mirizzi’s syndrome?
- Large stone in gallbladder presses on the common hepatic duct
- Obstructive jaundice
- Stone may erode through into the ducts
Describe Gallstone ileus?
- Large stone erodes from gallbladder into duodenum
- Through cholecysto-duodenal fistula
- Rigler’s triad:
- Pneumobilia
- Small bowel obstruction
- Gallstones in RLQ
Treatment for Gallstone ileus?
Stone removal through enterotomy
Features of obstructive jaundice?
- Jaundice
- Pale stools
- Dark urine
Describe Courvoisier’s law?
- 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
Describe important components of an Open cholecystectomy?
- Right subcostal incision
- Injury to bile duct is main source of morbidity
What bacteria can cause wound infection following cholecystectomy?
- Organisms present in bile
- E. coli
- Klebsiella aerogenes
- Strep. faecalis
Describe postcholecestectomy syndrome?
- Postprandial flatulence, fat intolerance, epigastric/right hypochondrial pain
- More severe when cholecystectomy has been performed in absence of gallstones
