Gallstones and Gallbladder Disease Flashcards
Summarize the steps of gallstone formation
• Increased cholesterol and decreased solubilizing bile salts → supersaturation (cholesterol saturation index >1)
• Relative concentrations of bile salts, phospholipids, and cholesterol = serve as nidus for crystal nucleation
• Crystal entrapment in mucus
o Creates suspension “sludge”
• Crystal nucleation + stasis (hypomotility) → cholelithiasis
Types of gallstones
Cholesterol • 90% of stones • From too much cholesterol and too few bile salts Risk factors: • Elevated estrogen (F>M) • Adults • Obesity (increased hepatic cholesterol secretion) • Rapid weight loss • Oral contraceptives • Ileal bypass, disease or resection
Pigmented
• 10% of stones
• Black = hemolysis or liver disease
• Brown = infection of bile ducts
Mixed
Define the term “nucleation time” and list possible nucleation factors
Nucleation time = time taken for crystal formation
Possible factors:
o Bacterial nidus
o Mucoproteins and protein content of bile → biliary sludge and gallstone formation
Symptomatic cholelithiasis
o Biliary colic = pain related to a gallstone in cystic duct
• Localized in epigastric or RUQ region
• Sudden onset without precipitating symptoms
• Rapidly increasing intensity over 15 minute period; can last as long as 3 hours
o Treat: cholecystectomy
Acute cholecystitis
o Acute inflammation of gallbladder due to cystic duct obstruction with stone
o Present: severe RUQ pain with fever, elevated WBC, tenderness to RUQ palapation → difficulty with inspiration (Murphy’s sign)
o CT: thickened gallbladder, pericholecystic fluid
o Treat: cholecystectomy within 48 hours
o At risk for: perforation, gangrene
Chronic cholecystitis
o Stones → chronic irritation/inflammation → fibrosis/thickening of gall bladder wall
o Chronic post-prandial RUQ pain
o CT: non-distended thickened gallbladder, cholelithiasis
• Porcelain gallbladder = up to 30% risk of gallbladder cancer
o Treat: cholecystectomy
Ascending cholangitis
o Acute bacterial infection superimposed on obstructed biliary tree
• A choledocholithiasis + infection (E. coli, Klebsiella, Enterobacter species)
o Present: RUQ pain, fever, jaundice (Charcot’s triad)
o More severe cases = also have hypotension and altered mental status (Reynod’s pentad)
Treat: IV fluids, antibiotics, lab assessment and imaging, ERCP/PTC
• PTC (Percutatneous Transhepatic Cholangiogram) = allows drainage of debris and inflammation
Choledocholithiasis
o Stone in ducts of biliary tract
o Treat: ERCP with sphincterotomy and stone extraction
Gallstone pancreatitis (Acute pancreatitis secondary to gallstones)
o Gallstone obstruction of pancreatic duct
o Present: epigastric pain radiating to back, nausea, vomiting, elevated lipase and amylase
o CT: peri-pancreatic inflammation, dilated bile ducts, cholelithiasis
o Note: acute pancreatitis can also be from a complication of ERCP when evaluating and removing gallstones
o Treat: IV fluids, medially stabilize, ERCP stone extraction
Treatment of cholangitis (due to choledocholithiasis)/Gallstone pancreatitis:
Goal: decompression and drainage of biliary tract
Endoscopic spincterotomy of sphincter of Oddi
• Via ERCP
• 90% successful
• Lower efficacy for stones above strictures
Stenting
• Allows for chronic drainage
• Infrequently indicated (may be used for failed stone extraction with initial ERCP)
Percutaneous extraction
• >90% successful
• Surgically placed T-tube = allows for extraction of retained stones post-op
Dissolution
• Primarily for cholesterol stones
• Infrequently indicated
• Occasionally used for unusual biliary anatomy or stone location
Charcot’s Triad
Occurs in Cholangitis (choledocholithiasis plus infection)
Fever
Abdominal pain
Jaundice
Reynold’s Pentad
Occurs in severe cholangitis (choledocholithiasis plus infection)
Fever Abdominal pain Jaundice Confusion Hypotension
