Gallstones and biliary colic

Question 1

What are gallstones and biliary colic?

Answer 1

Biliary colic = gallbladder attack = pain caused by bile/cystic duct obstruction (due to gallstone)

Cholelithiasis = solid concretions (gallstones) in gallbladder

Choledocholithiasis = solid concretions formed in gallbladder and exiting through bile duct

Question 2

What is the aetiology of gallstones and biliary colic?

Answer 2

Cholelithiasis – 80% asymptomatic and Gallstone presence incidental finding

Most frequently - obstruction of common bile duct OR cystic duct (Rarer – pancreatic duct)

Can be associated with functional disorders of the biliary tract -> acalculous biliary pain = pain without presence of gallstone obstruction, can be post-cholecystectomy

Question 3

What are the risk factors for gallstones and biliary colic?

Answer 3

Gallstone risk factors – 6Fs
Fat
Fair
Forty (>40 y/o)
Fertile (pregnancy, parity, OCP)
Female
FHx

DM
Prolonged fasting
TPN
Rapid weight loss

Question 4

What is the epidemiology of gallstones and biliary colic?

Answer 4

Prevalence:
10-15% – Europe + US
Low - Africa and Asia

1-2% previously asymptomatic -> biliary colic -> 50% recurrent pain

Question 5

What are the symptoms of gallstones and biliary colic?

Answer 5

RUQ pain radiating to back - severe, Sharp, colicky
Post prandial - fatty meal, Longer than 30 mins

Nausea and vomiting

Jaundice (cholangitis)

Question 6

What are the signs of gallstones and biliary colic?

Answer 6

Jaundice
Normal vital signs
Murphy’s + Boas negative (If Positive = cholecystitis)

Murphy’s – press just under right costal margin and pt wince on inspiration
Boas – pain radiate to scapula

Question 7

What are appropriate investigations for gallstones and biliary colic?

Answer 7

1st line = LFTs – raised ALP

Gold standard = Ultrasound – biliary tree
Specificity and sensitivity of >95%
See stones or dilated bile duct

Other investigations
ERCP - Only if suggested by lab tests

Question 8

How can gallstones and biliary colic be managed?

Answer 8

Medical - Antiemetics, Analgesia, Anti-inflammatory

Surgical - Laparoscopic cholecystectomy (Lap chole)

Recurrent biliary colic
ERCP – endoscope retrograde choleo-prancreatography
(Remove stone in cystic/common bile duct)

Question 9

What are the possible complications of gallstones and biliary colic?

Answer 9

Cholecystitis - Gallstone in cystic duct + gut bacteria -> gallbladder inflammation
RUQ pain (constant, rebound tenderness), fever, nausea, vomiting
Boas + murphy’s signs

Cholangitis - Gallstone in common bile duct + gut bacteria-> biliary tree inflammation
Charcot’s triad – fever + rigors, jaundice, RUQ pain (constant, rebound tenderness)
Reynold’s pentad = sepsis – hypotension, confusion, fever + rigors, jaundice, RUQ pain

Pancreatitis - Gallstone in hepatopancreatic ampulla of vater -> pancreas inflammation

Gallstone ileus = impacted in ileocecal valve

Gallbladder perforation

Obstructive jaundice

Post-cholecystectomy syndrome = acalculous biliary pain = pain in absence of gallstones

Question 10

What is the prognosis of gallstones and biliary colic?

Answer 10

30% have problems related to gallstones in the year following an attack
15% will go on to develop cholecystitis