Gallstones B&B

Question 1

which type of gallstones are not visible on x-ray (radiolucent)?

which type of gallstones ARE visible on x-ray (radiopaque)?

Answer 1

cholesterol gallstones = radiolucent… this doesn’t matter though, because we don’t use x-ray for dx anymore

pigment gallstones = radiopaque

Question 2

which patients most commonly present with cholesterol gallstones? which patients notably do NOT?

Answer 2

cholesterol gallstones are most common in adults around 40 years old

rare in children and elderly… elderly patient with gallstones = cancer

Question 3

elderly patient presenting with symptoms of gallstones =

Answer 3

gallstone cancer

because cholesterol gallstones are most common in adults around 40 years old (rare in children + elderly)

Question 4

3 risk factors for cholesterol gallstones (general principles)

Answer 4

1. excess estrogen —> increases cholesterol
2. altered lipid metabolism —> excess cholesterol in bile
3. loss of bile salts —> loss of cholesterol emulsification

Question 5

explain why pregnant women have a higher incidence of cholesterol gallstones (2 reasons)

Answer 5

1. estrogen increases cholesterol synthesis
2. progesterone slows gallbladder emptying

Question 6

explain why rapid weight loss increases the risk of gallstones

Answer 6

rapid weight loss increases cholesterol mobilization —> increased risk of precipitation and cholesterol gallstones

[obesity is also risk factor because of increased total body cholesterol]

Question 7

poor reabsorption of bile salts from the ______ can increase risk of cholesterol gallstones

Answer 7

poor reabsorption of bile salts from the terminal ileum can increase risk of cholesterol gallstones

for example, due to Crohn’s Disease (causes inflammation of ileum)

[recall ~95% of bile salts are reabsorbed and recycled]

Question 8

which drugs used to treat hypercholesterolemia increase the risk of gallstones?

Answer 8

fibrates (ex: clofibrate): inhibit bile acid synthesis

less bile acids = less cholesterol emulsification = cholesterol gallstone precipitation

Question 9

what is the cause (generally speaking) of pigment stones?

Answer 9

aka bilirubin stones - composed of calcium bilirubinate

occur because unconjugated bilirubin is insoluble in water —> anything that increases levels of unconjugated bilirubin will increase risk of pigment stones

appear black/brown, radiopaque (can be seen on x-ray)

Question 10

explain how recurrent biliary tree infections can increase the risk for gallstones

Answer 10

bacteria producing glucuronidases can convert conjugated bilirubin to unconjugated

these pigment stones appear brown (not black like those caused by extravascular hemolysis or cirrhosis) because there is still some cholesterol

Question 11

what is the clinical use of ursodeoxycholic acid?

Answer 11

bile acid rarely used except sometimes for treatment of cholesterol stones (NOT pigment stones)

reduces cholesterol secretion into bile, may dissolve gallstones

only really used if someone doesn’t want to have surgery for their gallstones

Question 12

patient complaining of pain in their right shoulder blade after meals should raise suspicion for…

Answer 12

gallstones - cause colicky (wax/wane) RUQ pain that radiates to R shoulder blade

pain occurs after meals (esp. fatty meals) because CCK stimulates gallbladder contraction

Question 13

which hormone stimulates gallbladder contraction?

Answer 13

cholecystokinin (CCK)

Question 14

a positive Murphy’s sign raises suspicion for…

Answer 14

Murphy’s sign: press on RUQ and ask patient to inspire… if they stop abruptly due to pain, high suspicion for acute cholecystitis

(gallstone blocking duct)

treat w/ urgent surgery due to risk of rupture/peritonitis

Question 15

cholecystitis vs choledocolithiasis

Answer 15

cholecystitis = gallstone in cystic duct causing obstruction and inflammation of gallbladder

choledocolithiasis = gallstone in common bile duct causing biliary obstruction and jaundice

Question 16

what is the characteristic x-ray finding of chronic cholecystitis? what is the feared clinical risk?

Answer 16

porcelain gallbladder - edges appear white due to calcification

risk of gallbladder carcinoma, so gallbladder is surgically removed

Question 17

a “porcelain gallbladder” on x-ray =

Answer 17

chronic cholecystitis - long-standing, untreated cholecystitis that causes chronic inflammation

risk of gallbladder carcinoma, so gallbladder is surgically removed

Question 18

what is the cause of acalculous cholecystitis?

Answer 18

acute cholecystitis NOT due to gallstones, but rather ischemia and stasis of gallbladder

occurs in critically ill patients (ICU)

Question 19

which 2 infectious agents most commonly cause AIDS cholangiopathy?

Answer 19

1. cryptosporidium - most common
2. cytomegalovirus

rare complication of HIV (CD4<100), biliary obstruction from strictures of biliary tract causes RUQ pain, jaundice, fever

Question 20

what is the classic triad of ascending cholangitis? which 2 additional symptoms indicate sepsis and shock?

Answer 20

ascending cholangitis: gallstone blocks flow of bile and GI bacteria ascend to biliary tree (gram neg. like E. coli, Klebsiella, Enterobacter)

Charcot’s triad = fever + abdominal pain + jaundice

Reynolds pentad = fever + abdominal pain + jaundice + confusion + hypotension

Question 21

rare helminth cause of ascending cholangitis that is found in infected fish (like bad sushi)

Answer 21

clonorchis sinensis: Chinese liver fluke

will see symptoms of ascending cholangitis (fever + abdominal pain + jaundice) + peripheral eosinophilia

Question 22

Pt presents to ED w/ fever and abdominal pain. PE is notable for jaundice. Labs show elevated alkaline phosphatase and conjugated bilirubin, as well as elevated eosinophils. The patient says their diet consists of a lot of fish and sushi. Dx?

Answer 22

clonorchis sinensis: Chinese liver fluke, helminth that rarely causes ascending cholangitis

will see symptoms of ascending cholangitis (fever + abdominal pain + jaundice) + peripheral eosinophilia

Question 23

what is the key imaging finding of gallstone illeus?

Answer 23

gallstone illeus: massive gallstones erodes through gallbladder and creates fistula with small intestine

x-ray or CT scan will show air in biliary tree due to air from intestine

Question 24

air in biliary tree seen on x-ray or CT scan =

Answer 24

gallstone illeus: massive gallstones erodes through gallbladder and creates fistula with small intestine

Question 25

chronic infection with which organism can cause gallbladder carcinoma?

Answer 25

chronic Salmonella typhi infection because it remains in gallbladder during carrier state