Gallstones

Question 1

What is the epidemiology of gallstones?

Answer 1

Affects 10-15% of adults

Question 2

What are the 3 types of stones?

Answer 2

1. CHOLESTEROL GALLSTONES (MOST COMMON)
2. BILE PIGMENT STONES:
   - Small and dark
   - Comprise of bilirubin and calcium salts found in bile
3. MIXED STONES:
   - Usually contain cholesterol + calcium salts

Question 3

What is the aetiology of gall stones?

Answer 3

· Cause of cholesterol stones (90%):

• Obesity.
• Total parental nutrition.
• Rapid weight loss.
• Medications.

· Black pigment stones (2%):

• Chronic haemolytic anaemia.
• Cirrhosis.
• CF.
• Ileal diseases.

· Brown pigment stones:

• Bacterial infection.
• Biliary parasites.
• Stasis.
• Biliary strictures.

Question 4

What risk factors are associated with gallstones?

Answer 4

· Older age.
· Female.
· Pregnancy.
· Obesity, diabetes and metabolic syndrome.
· Rapid weight loss.
· Drugs.
· Family history.

Question 5

What signs and symptoms are associated with gallstones?

Answer 5

· 90% = ASYMPTOMATIC

· RUQ/Epigastric biliary pain and tenderness on palpation:

• Obstruction of cystic duct or obstruction and/or passage of the gallstone with the CBD.
• Sometimes after consumption of food.
• Constant pain, increasing in intensity, lasting for several hours (at least 30 minutes).
• Pain >5 hours suggests cholecystitis or another complication.

· Nausea.
· Jaundice.
· CHOLANGITIS – bile duct infection:
- Bile duct infection causing RUQ pain, jaundice, rigors

Question 6

What technique is used to detect gallstones during an examination?

Answer 6

MURPHY’S SIGN - elicited in pts with acute cholecystitis by asking the pt to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand,Murphy’s signis +ve.

Question 7

What investigations would you request if you suspected someone had gallstones?

Answer 7

· FBC - High WCC suggests cholecystitis, cholangitis or pancreatitis. Normal is simple biliary colic.
· U&E’s
· LFT’s - If obstructed, raised ALP and bilirubin. Normal with cholelithiasis.
· Amylase and lipase - for
· Abdo USS - best way to look for stones.
· Abdo CT.
· If gallstones in gallbladder or ducts - MRCP.

Question 8

What are the differential diagnoses associated with gallstones?

Answer 8

· Peptic ulcer disease.
· Gallbladder cancer - painless jaundice.
· Gallbladder polyps.
· Non-biliary acute pancreatitis.

Question 9

What treatment options are available for gallstones?

Answer 9

· Symptomatic gallstones:
- 1st line - cholecystectomy.

· Gallstones in ducts (cholecholithiasis) with or without symptoms:

• 1st line - ERCP.
• Adjunct - Lithotripsy, papillary balloon dilatation or long-term biliary stenting.
• 2nd line - Laparoscopic CBD exploration.

· Asymptomatic gallstones:
- Observation.

· Analgesia for pain - morphine or pethidine.

Question 10

What complications can arise from gallstones?

Answer 10

· Cholecystitis.
· Cholangitis 
· Pancreatitis.
· ERCP-associated pancreatitis.
· Iatrogenic bile duct injuries.
· Mirizzi’s syndrome