Gallstones and Biliary Colic

Question 1

Define gallstones

Answer 1

Stone formation in the gallbladder

Bile contains:

• Cholesterol
• Phospholipids
• Bile pigments (broken down Hb)

Question 2

Causes of gallstones

Answer 2

With varying concentrations, different stones form:

1. Pigment stones – (<10%), small, friable (easily crumbled), irregular, radiolucent → associated with haemolytic disorders (sickle cell, thalassemia, spherocytosis)
   
   • Ether black calcium bilirubinate stones (↑bilirubin due to haemolysis or cirrhosis) or brown due to stasis and infection (e.g. bile duct infestation by liver fluke Clonorchis sinesis)
2. Mixed stones – faceted (Ca2+ salts, pigment and cholesterol) 10% radio-opaque
   
   • Associated with ↑age, F, obese, parental nutrition, drugs (OCP, octreotide), FHx, ethnicity, Crohn’s, ileal resection
3.  Cholesterol stones – (10%) large, often solitary, radiolucent Causes: F, ↑age, obese (similar to mixed)

Question 3

Risk factors of gallstones

Answer 3

fair, fat , female, fertile, forty

Question 4

Epidemilogy of gallstones

Answer 4

• very COMMON
• 8% of those over 40 years, more common with age
• 3x more females in younger pop, equal sex ratio after 65 years

Question 5

Symptoms of gallstones

Answer 5

90% cases are asymptomatic
Risk factors (for becoming symptomatic) → smoking, parity

Most common presentation: biliary colic

Question 6

Define biliary colic

Answer 6

Pain resulting from obstruction of the gallbladder or common bile duct, usually by a stone

• The pain, which is very severe, is usually felt in the upper abdomen (in the midline or to the right) but can also be poorly localised due to its visceral nature.
• Right upper quadrant/ epigastric pain

Question 7

Causes of biliary colic

Answer 7

• Occurs due to contractions of the biliary tree in an attempt to relieve an obstruction (e.g. due to a stone)
• Symptomatic gallstones with cystic duct obstruction or if passed into the CBD

Question 8

Symptoms of biliary colic

Answer 8

• Crampy RUQ pain
• Nausea and vomiting
• Pain may radiate to the right scapula
• The pain does NOT fluctuate and has a tendency to persist
• Individuals may present with pain following ingestion of a fatty meal

Question 9

Signs of biliary colic on physical examination

Answer 9

RUQ pain and epigastric tenderness

Question 10

Investigations for gallstones and biliary colic

Answer 10

1. Urinalysis, CXR and ECG to exclude other causes (e.g. basal pneumonia, inferior MI)
2. Ultrasound
   
   • Look for dilatation of the CBD
   • Gallbladder wall may be thickened
3. LFT
   
   • Elevated alkaline phosphatase suggests obstruction of the cystic or bile duct.
4. ERCP - useful diagnostically and therapeutically
5. CT - may be useful if other forms of imaging have been insufficient
6. Amylase to exclude pancreatitis

Question 11

Management

Answer 11

• Analgesia
• IV fluids

Surgical

• Laparoscopic cholecystectomy
• ERCP can also be used to help remove stones or stent a blocked bile duct

Question 12

Complications

Answer 12

Complications of gallstones:

GB and cystic duct:

• Biliary colic
• Acute/ chronic cholecystitis
• Mucococele: obstructed GB fills witg mucus
• Empyema: obstructed GB fillss with pus
• Carcinoma

In the bile duct:

• Obstructive jaundice
• Cholangiatis
• Pancreatitis

Complications of surgery

• Injury to the bile duct
• Fat intolerance - due to inability to secrete a large amount of bile into the intestine because the patient no longer has a gallbladder
• Post-cholecystectomy syndrome - presence of abdominal symptoms (e.g. dyspepsia, nausea/vomiting, RUQ pain) after the removal of the gallbladder

Question 13

Prognosis

Answer 13

GOOD prognosis with appropriate treatment