Gallstones and Biliary Colic

Question 1

Define Gallstones and Biliary Colic

Answer 1

Presence of solid concretions on the gallbladder

AKA cholelithiasis

Biliary colic = pain due to gallstone temporarily blocking the bile duct

Question 2

Aetiology of Gallstones and Biliary Colic

Answer 2

Gallstone composition: Cholesterol (90%), pigment, calcium, bilirubin

Bile supersaturation with cholesterol (liver secretes excess amounts) | accelerated nucleation aids chol. precipitation | gallbladder hypomotility

Gallbladder contracts causing the gallstone to be lodged in the cystic duct, bile duct or pancreatic duct -> biliary colic

Question 3

Risk factors for Gallstones and Biliary Colic

Answer 3

4 F's: Fat, fertile, forties, female 
Cholesterol: obesity, rapid weight loss, medications 
Haemoglobinopathy 
Crohn's 
Cirrhosis

Question 4

Symptoms of Gallstones and Biliary Colic

Answer 4

Asymptomatic gallstone sin 80%

RUQ/epigastric pain (>30 mins | constant pain, increases in intensity | responds to analgesia | post-prandial)
Dyspepsia, heartburn, flatulence, bloating
Nausea

Jaundice uncommon, unless Mirizzi syndrome

Question 5

What is Mirizzi syndrome

Answer 5

Gallstone lodged in the neck of the gallbladder causes compression of the common bile or hepatic duct

Question 6

Signs of Gallstones and Biliary Colic

Answer 6

RUQ/epigastric tenderness

Murphy’s sign: respiratory arrest upon deep inspiration on palpation of the biliary fossa (cholecystitis)

Question 7

Investigations for Gallstones and Biliary Colic

Answer 7

USS abdomen: cholelithiasis or choledocholithiasis (presence of stone or duct dilation)

LFTs: normal if uncomplicated, elevated ALP and GGT + bilirubin if choledocholithiasis
FBC: normal if uncomplicated, raised WCC in cholecystitis + cholangitis
Serum lipase/amylase: normal (exclude pancreatitis)

MRCP: Stone in gallbladder or bile duct (if USS is -ve)
EUS: stones in gallbladder or bile duct
CT abdomen: exclude differentials - may see duct dilation in cholangitis

Question 8

Management for Gallstones and Biliary Colic - cholelithiasis (asymptomatic + symptomatic)

Answer 8

Asymptomatic: observation

Symptomatic:

1. Analgesia e.g. paracetamol or diclofenac ± anti-spasmodic e.g. hycosine
2. Cholecystectomy (elective if no cholecystitis features)

Question 9

Management for choledocholithiasis

Answer 9

1. Bile duct clearance via ERCP + biliary sphincterotomy and stone extraction

OR

Laparascopic commino bile duct exploration + lap chole

2. Analgesia e.g paracetamol ± anti-spasmodic e.g. hycosine

Question 10

Complications of Gallstones and Biliary Colic

Answer 10

Acute cholecystitis
Cholangitis
Acute pancreatitis 
ERCP-associated pancreatitis 
Iatrogenic bile duct injury 
Gallstone ileus
Mirizzi syndrome 
Post-sphincterotomy bleeding

Question 11

Prognosis for Gallstones and Biliary Colic

Answer 11

Very few with asymptomatic stones experience major complications
Favourable prognosis for those managed by cholecystectomy or ERCP