Gallstones/Bile Duct Stones

Question 1

How common is it?

Answer 1

8% of those over 40 yrs. 90% remain asymptomatic.

Question 2

What causes it?

Answer 2

If concentrations of cholesterol, bile pigments and phospholipids in bile vary, stones form.

• Pigment stones (<10%) – small, friable and irregular. Caused by heamolysis.
• Cholesterol stones – large, often solitary. Causes – Male sex, age, obesity. Admirand’s triangle - ↑risk of stone if ↓lecithin, ↓bile salts, ↑cholesterol.
• Mixed stones – Faceted (calcium salts, pigment and cholesterol).

Question 3

Risk factors?

Answer 3

Risk factors for gallstones becoming symptomatic- smoking, parity.
Risk factors for cholecystitis:
- Gallstones or biliary sludge (95% of patients)
- Hospitalisation for trauma or acute biliary illness (this represents the other 5%, without gallstones)
- Female gender
- Increasing age
- Obesity
- Rapid weight loss
- Pregnancy
- Crohn’s disease
- Hyperlipidaemia

Question 4

How does it present?

Answer 4

Acute cholecystitis
Symptoms
- Continuous epigastric or RUQ pain (referred to the right shoulder).
- Vomiting, fever.

Signs

• Local peritonism, possible GB mass.
• Main difference from biliary colic is inflammatory component (local peritonism, fever, WCC↑).
• If stone moves to common bile duct, obstructive jaundice and cholangitis may occur).
• Murphy’s sign – Lay 2 fingers over RUQ, ask patient to breathe in. Causes pain and arrest of inspiration as an inflamed GB impinges on your fingers. Only +ve if same test doesn’t cause tenderness in LUQ.

Complications of gallstones

• In gallbladder & cystic duct – biliary colic, acute and chronic cholecystitis, mucocele, empyema, carcinoma, Mirizzi’s syndrome.
• In bile ducts – obstructive jaundice, cholangitis, pancreatitis.
• In gut – gallstone ileus.

Question 5

Similar presentations?

Answer 5

• Abdominal Aortic Aneurysm
• Chronic cholecystitis
• Biliary colic
• Acute Mesenteric Ischemia
• Appendicitis
• Biliary Colic
• Biliary Disease
• Cholangiocarcinoma
• Cholangitis
• Choledocholithiasis
• Cholelithiasis
• Gallbladder Cancer
• Gallbladder Mucocele
• Gallbladder Tumors
• Gastric Ulcers
• Acute Gastritis
• Acute pyelonephritis

Question 6

Investigations?

Answer 6

• ↑WCC
• US – shrunken, thick-walled GB, pericholecystic fluid, stones, CBD.
• Plain AXR only shows 10% of gallstones.

Question 7

Treatments?

Answer 7

• NBM, pain relief, IVI and eg cefuroxime (IV).

- Laparoscopic cholecystectomy is treatment of choice.