Gallstones, Ascending cholangitis and Cholecystitis

Question 1

What are gallstones?

Answer 1

This is the presence of solid concretions in the gallbladder.

Question 2

Where would you find gallstones?

Answer 2

Gallstones form in the gallbladder but may exit into the bile ducts (choledocholithiasis).

Question 3

When are gallstones symptomatic?

Answer 3

Symptoms ensues if a stone obstructs the cystic, bile or pancreatic duct.
Transient obstruction of the cystic duct results in biliary pain.
More persistent obstruction leads to acute cholecystitis.

Question 4

What are gallstones made up of?

Answer 4

Most gallstones in developed countries consist of cholesterol.
There are 3 types of gallstones:
Cholesterol (90%) 
Black pigment (5-10%)
Brown pigment

Question 5

Risk factors for cholesterol gallstones

Answer 5

Family history 
Diet (obesity, metabolic syndrome, sudden weight reduction) 
Age 
Female sex hormones
People using somatostatin
Those receiving parenteral nutrition
Bariatic surgery 
Rapid weight loss

Question 6

Where does typical biliary pain occur?

Answer 6

Right upper quadrant (RUQ) or epigastric area.

The constant pain increases in intensity and lasts for several hours.

Question 7

Associated symptoms of biliary pain

Answer 7

Fever suggests cholecystitis

Jaundice tends to accompany cholangitis or pancreatitis.

Question 8

Management approach

Answer 8

Ultrasound is the best test for suspected biliary pain.
FBCs
Liver function tests
Serum lipase and amylase
MRI, CT scan (tests to consider)
Laparoscopic cholecystectomy is the best treatment for gallstones.

Question 9

Primary prevention of gallstones

Answer 9

A diet high in fibre, low in saturated fat.

Maintenance of a normal body weight, coupled with moderate physical activity.

Question 10

What is cholangitis?

Answer 10

Cholangitis is an infection of the biliary tree that requires prompt diagnosis and treatment.

Question 11

Symptoms of ascending cholangitis

Answer 11

Fever, jaundice and RUQ pain (Charcot’s triad)

Question 12

A major complication of ascending cholangitis

Answer 12

Cholangitis can quickly become an acute, septic, life-threatening infection.
If untreated, sepsis with shock, vascular collapse, multi-organ failure and potentially death can occur

Question 13

Common causes of ascending cholangitis

Answer 13

Choledocholithiasis

Benign and malignant strictures

Question 14

Pathophysiology of ascending cholangitis

Answer 14

Obstruction of the common bile duct results in bacterial seeding of the biliary tree, possibly via the portal vein.
Combined with bacterial contamination leads to acute cholangitis.
The bacterial infection ASCENDS from the biliary tree junction with the duodenum

Question 15

Risk factors for ascending cholangitis

Answer 15

Over 50
History of gallstones
Stricture of the biliary tree

Question 16

Investigations of ascending cholangitis

Answer 16

FBC 
Serum Urea and creatinine 
ABG (sepsis) 
CRP 
K+ and Mg2+
Blood cultures 
Coagulation panel 
ERCP
Ultrasound 
MRI (2nd line) 
CT scan (2nd line) 
Surgery (2nd line)

Question 17

Management of ascending cholangitis

Answer 17

IV antibiotics (tazobactam-piperacillin)
Intensive medical management
Biliary decompression: non-operative
WITH: lithotripsy + opioid analgesics

Question 18

Differentials of ascending cholangitis

Answer 18

Peptic ulcer disease 
Acute pancreatitis
Hepatic abscess
Acute appendicitis 
Right lower lobe pneumonia

Question 19

Difference between biliary obstruction due to gallstones or pancreatic cancer

Answer 19

Biliary obstruction due to gall stones is usually accompanied by repeated biliary colic and or attacks of cholangitis, hence will present early with painful jaundice and minimal dilatation of the bile ducts.
On the other hand, diseases such as “carcinoma of the head of pancreas” or “carcinoma of the Ampulla of Vater” will present with progressively worsening painless jaundice and marked dilatation of the biliary tree. Of course, there will always be exceptions.