Gallstones B&B Flashcards
which type of gallstones are not visible on x-ray (radiolucent)?
which type of gallstones ARE visible on x-ray (radiopaque)?
cholesterol gallstones = radiolucent… this doesn’t matter though, because we don’t use x-ray for dx anymore
pigment gallstones = radiopaque
which patients most commonly present with cholesterol gallstones? which patients notably do NOT?
cholesterol gallstones are most common in adults around 40 years old
rare in children and elderly… elderly patient with gallstones = cancer
elderly patient presenting with symptoms of gallstones =
gallstone cancer
because cholesterol gallstones are most common in adults around 40 years old (rare in children + elderly)
3 risk factors for cholesterol gallstones (general principles)
- excess estrogen —> increases cholesterol
- altered lipid metabolism —> excess cholesterol in bile
- loss of bile salts —> loss of cholesterol emulsification
explain why pregnant women have a higher incidence of cholesterol gallstones (2 reasons)
- estrogen increases cholesterol synthesis
- progesterone slows gallbladder emptying
explain why rapid weight loss increases the risk of gallstones
rapid weight loss increases cholesterol mobilization —> increased risk of precipitation and cholesterol gallstones
[obesity is also risk factor because of increased total body cholesterol]
poor reabsorption of bile salts from the ______ can increase risk of cholesterol gallstones
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]
which drugs used to treat hypercholesterolemia increase the risk of gallstones?
fibrates (ex: clofibrate): inhibit bile acid synthesis
less bile acids = less cholesterol emulsification = cholesterol gallstone precipitation
what is the cause (generally speaking) of pigment stones?
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)
explain how recurrent biliary tree infections can increase the risk for gallstones
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
what is the clinical use of ursodeoxycholic acid?
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
patient complaining of pain in their right shoulder blade after meals should raise suspicion for…
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
which hormone stimulates gallbladder contraction?
cholecystokinin (CCK)
a positive Murphy’s sign raises suspicion for…
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
cholecystitis vs choledocolithiasis
cholecystitis = gallstone in cystic duct causing obstruction and inflammation of gallbladder
choledocolithiasis = gallstone in common bile duct causing biliary obstruction and jaundice
what is the characteristic x-ray finding of chronic cholecystitis? what is the feared clinical risk?
porcelain gallbladder - edges appear white due to calcification
risk of gallbladder carcinoma, so gallbladder is surgically removed
a “porcelain gallbladder” on x-ray =
chronic cholecystitis - long-standing, untreated cholecystitis that causes chronic inflammation
risk of gallbladder carcinoma, so gallbladder is surgically removed
what is the cause of acalculous cholecystitis?
acute cholecystitis NOT due to gallstones, but rather ischemia and stasis of gallbladder
occurs in critically ill patients (ICU)
which 2 infectious agents most commonly cause AIDS cholangiopathy?
- cryptosporidium - most common
- cytomegalovirus
rare complication of HIV (CD4<100), biliary obstruction from strictures of biliary tract causes RUQ pain, jaundice, fever
what is the classic triad of ascending cholangitis? which 2 additional symptoms indicate sepsis and shock?
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
rare helminth cause of ascending cholangitis that is found in infected fish (like bad sushi)
clonorchis sinensis: Chinese liver fluke
will see symptoms of ascending cholangitis (fever + abdominal pain + jaundice) + peripheral eosinophilia
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?
clonorchis sinensis: Chinese liver fluke, helminth that rarely causes ascending cholangitis
will see symptoms of ascending cholangitis (fever + abdominal pain + jaundice) + peripheral eosinophilia
what is the key imaging finding of gallstone illeus?
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
air in biliary tree seen on x-ray or CT scan =
gallstone illeus: massive gallstones erodes through gallbladder and creates fistula with small intestine
