Gallstones Flashcards
Define gallstones
The presence of solid concretions (stones) in the gallbladder
What is the pathophysiology of gallstones?
Pathophysiology depends on type of gallstone produced
CHOLESTEROL STONES (most common - 80% in UK):
- abnormal hepatic cholesterol metabolism
→ bile becomes hypersaturated with cholesterol
→ cholesterol precipitates out of the bile solution
→ cholesterol stones
There are other types of gallstones (black pigment and mixed) but they are less common
What is the aetiology of gallstones?
- Female (oestrogen increases cholesterol secretion into bile)
- COCP (oestrogen)
- Obesity (increased cholesterol)
- Rapid weight loss (increased cholesterol mobilisation from adipose tissue → more cholesterol secreted into bile)
- Malabsorption (e.g. Crohn’s disease)
Malabsorption → interruption of the enterohepatic recirculation of bile salts → you need bile salts to hold the cholesterol in solution → less bile salts = more cholesterol precipitation
What are the risk factors for gallstones?
6Fs:
- Fat
- Female
- Fertile
- Fair-skinned
- Forty (increasing age)
- Family history
Others:
- Taking COCP
- Malabsorption (e.g. Crohn’s)
- Rapid weight loss
What is the epidemiology of gallstones?
- Very common (UK prevalence approx. 10%)
- More common with age
- More common in females in younger population
- Equal sex ratio after 65 years
What are the presenting symptoms of gallstones?
Most patients (90%) are asymptomatic
MAIN SYMPTOM:
Biliary colic = sudden onset, severe RUQ pain, constant in nature
(colic is a pain that occurs when substances are trying to move past the obstruction)
Biliary colic:
- Pain may radiate to epigastrium or right shoulder (referred pain)
- Pain can last hours
- Often precipitated by a fatty meal (stimulates bile release from gallbladder)
- Can have nausea and vomiting with it
What are the presenting signs of gallstones?
RUQ or epigastric tenderness
What investigations would you do if you were suspecting gallstones and what would you expect to see?
1st line - diagnostic:
- Abdominal ultrasound
1st line - to rule out other causes of acute RUQ or epigastric pain:
- FBC (↑ WBC in cholecystitis or cholangitis)
- Serum LFTs (↑ alkaline phosphate and bilirubin in cholangitis)
- Serum amylase (↑ in acute pancreatitis)
Other forms of imaging:
- Abdominal CT scan
- Magnetic resonance cholangiopancreatography (MRCP)
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Erect chest x-ray (to exclude perforation)
What is the management for gallstones?
Asymptomatic gallstones in gallbladder:
- Conservative (do nothing)
- Avoidance of fat in diet
Asymptomatic gallstones in common bile duct:
- Bile duct clearance and laparoscopic cholecystectomy
(significant risk of developing serious complications such as cholangitis or pancreatitis)
Symptomatic gallstones:
- Analgaesia (diclofenac - IM if severe, oral if mild to moderate pain)
- Surgery - laparoscopic cholecystectomy
- ERCP can also be used to help remove stones or stent a blocked bile duct
What is are the complications of gallstones?
Gallstones in gallbladder:
- Cholecystitis
- Porcelain gallbladder
(calcification of the gallbladder wall due to chronic inflammation)
- Gallbladder mucocele
(marked distension of the gallbladder with sterile mucinous content due to chronic biliary outflow obstruction)
Gallstones outside gallbladder: - Obstructive jaundice - Acute pancreatitis - Ascending cholangitis - Mirizzi syndrome (common hepatic duct obstruction by an extrinsic compression from an impacted stone in the cystic duct)
Cholescystectomy:
- Injury to the bile duct
- Fat intolerance (due to inability to secrete a large amount of bile into the intestine)
- Post-cholecystectomy syndrome (persistent dyspeptic symptoms)
What is the prognosis for gallstones?
Good prognosis with appropriate treatment
