Gallstones and Biliary Colic Flashcards
Are gallstones common?
highly prevalent, but most cases are asymptomatic
What is biliary colic?
gallstones are symptomatic with cystic duct obstruction or if passed into common bile duct (CBD)
What are the risk factors for gallstones?
- Increasing Age
- Female sex
- Obesity diabetes and metabolic syndrome
- FHx of gallstones
- Gene mutations
- pregnancy/exogenous oestrogen
- non-alcoholic liver disease
- prolonged fasting/rapid weight loss
- total parenteral nutrition (TPN)
- medication
- terminal ileum disease or resection
- haemoglobinopathy
- Hispanic and Native-American ethnicity
What are the different types of stones in the biliary tract?
- Cholesterol gallstones
- Black pigment gallstones
- Brown pigment stones (ductal stones)
What are the most common type of stone?
90% of gallstones are made of cholesterol and formed in the gallbladder
What are pigment stones like and their causes?
small, friable and irregular (cause: haemolysis - calcium bilirubinate)
What are cholesterol stones like and their causes?
large often solitary (causes: age, sex, obesity)
What are the symptoms of gallstones like?
- right upper quadrant (RUQ) or epigastric pain (tenderness)
- Radiates to the right back or shoulder
- Responds to analgesia
- Typically occurs approximately 1 hour after consumption of food, often in the evening
- May wake the patient from sleep
- May be accompanied by nausea
- Becomes increasingly intense and then stabilises
- Typically lasts for at least 15 to 30 minutes and up to several hours.
- Sometimes Jaundice
What are some differential diagnosis of gallstones?
- Peptic ulcer disease (PUD)
- Gallbladder cancer
- Gallbladder polyps
- Acalculous cholecystitis
- Sphincter of Oddi dysfunction (SOD)
- Non-biliary acute pancreatitis
What are the first line investigations for gallstones?
- Abdominal US
- Serum LFTs
- FBC
- Serum lipase or amylase
How would cholelithiasis show in US?
stones in the gallbladder
How would choledocholithiasis show in US?
stones in the bile duct with or without bile duct dilation
How would serum LFTs look like in uncomplicated cholelithiasis?
normal
How would serum LFTs look like in choledocholithiasis?
- elevated alkaline phosphatase
- elevated bilirubin
How would FBC look in different types of gallstones?
- normal WBC in simple (uncomplicated) biliary colic
2. elevated WBC in acute cholecystitis, cholangitis, or pancreatitis
Why do you measure serum lipase or amylase?
elevated (>3 times upper limit of normal) in acute pancreatitis
What other investigations would you consider?
- MRCP
- EUS
- Abdominal CT
What is the 1st line treatment of acute symptomatic cholelithasis?
1st line: Analgesia (NSAIDs)
Consider: Anti-spasmodic
Plus: cholecystectomy
What is the 1st line treatment in choledocholithiasis with or without symptoms?
1st line: bile duct clearance and laparoscopic cholecystectomy
Plus: analgesia
Consider: anti-spasmodic
What is the 2nd line treatment in choledocholithiasis with or without symptoms?
2nd line: temporary stenting prior to definitive biliary clearance
Consider: analgesia
How would you treat ongoing asymptomatic cholelithiasis?
observation
What are possible complications of gallstones?
- endoscopic retrograde cholangiopancreatography (ERCP)-associated pancreatitis
- iatrogenic bile duct injuries
- post-sphincterotomy bleeding
- Bouveret syndrome
- gallstone ileus
- acute cholecystitis
- acute cholangitis
- acute biliary pancreatitis
- Mirizzi syndrome
How common is gallstones?
- 8% of those over 40
- 90% remain asymptomatic
What are features of symptomatic cholelithiasis?
post-prandial RUQ pain
What is seen in US of symptomatic cholelithiasis?
stones in GB (acoustic shadow)
What is the initial managemnt of symptomatic cholelithiasis?
IF SYMPTOMATIC
Analgesia
What is the defintiive managemnt of symptomatic cholelithiasis?
Elective lap chole
What are complications of symptomatic cholelithiasis?
- Biliary colic
- acute cholecysitis
- choledocholithiasis
What are features of choledocholithiasis?
RUQ pain and sometimes jaundice
What can be found in US for choledocholithiasis?
US: stones in CBD +/-dilated CBD
What is the intial management of choledocholithiasis?
Analgesia
+
ERCP (regardless of symptoms)
What is the defintive management of choledocholithiasis?
Elective lap chole
What are complications of choledocholithiasis?
- Obstructive jaundice
- Acute cholangitis
- Pancreatitis
What are RF for gallstones?
- Fair
- Fat
- Fertile (1 or more kids)
- Female
- Forty
- +OCC, Crohn’s
What is cholelithiasis?
gallstone in gallbladder and if pain (bilary colic)
What is acute cholecytsis?
Cholelithiasis + inflammation ±secondary infection
Do you get jaundice in acute cholecystitis, cholelithiasis?
No Jaundice as not obstructing biliary flow but rarely, there can be mild jaundice in acute cholecystitis- inflammation of contiguous biliary ducts (Mirizzi’s syndrome)
What is choledocholithiasis?
Gallstone in CBD (if with pain biliary colic)
What is asceding cholangitis?
Choledocholithiasis + infection
Is there jaundice in choledocholithiasis and ascending cholangitis?
May be jaundice/raised ALP/GGT
Obstruction to biliary flow
What can a result of ERCP be?
ERCP can lead to pancreatitis in 3-5% of patients
How do you Ix cholecystitis?
1st line: USS liver and biliary tree
How do you tell the difference between biliary colic vs cholecystitis?
In cholecystitis signs of infection and inflammation: Fever, WCC/CRP and Murphy’s signs positive
What are common complications of gallstones?
- GB empyema
- Gallstone ileus
