Gallstones + Biliary Colic Flashcards
What is Cholelithiathis?
presence of solid deposits (stones) in the gallbladder.
What is Choledocoliathisis?
Gallstones in the CBD
What is acute cholecystitis?
Acute inflammation of the gallbladder
Typically due to cystic duct obstruction by a gallstone
What is ascending cholangitis?
Ascending bacterial infection of biliary tract facilitated by bile stasis
Caused by combination of biliary outflow obstruction + biliary infection
What is Biliary Colic?
RUQ pain caused by gallbladder, cystic duct or CBD contracting around a gallstone
Most common complication of gallstones
List the 3 types of gallstone
Pure Cholesterol Stones: MOST COMMON
Mixed stones
Pigment Stones
Describe pigment stones
Black stones made of calcium bilirubinate
Form due to increased BR (e.g. due to haemolysis/ cirrhosis)
Brown stones due to bacterial infection, strictures (PBC) or biliary parasites
Describe mixed stones
Contain cholesterol, calcium bilirubinate, phosphate + protein
Form due to imbalance between bile salts, phospholipids, cholesterol, nucleation factors + gallbladder motility
Describe the epidemiology of gallstones
Very COMMON
UK prevalence of gallstone disease = 10-15% (only 1-2% become symptomatic)
F > M in younger population
More common with increasing age
List 5 F’s and 2 additional risk factors for gallstones
Female (oestrogen increases risk)
Fertile/ pregnant (oestrogen increases risk + HRT)
40 (increases with age)
Fat
FH
Diabetes mellitus
Drugs (OCP, octreotide)
What is the classical presenting complaint of biliary colic?
Colicky RUQ pain postprandially
Constant pain 30 mins- 8h
Sx worst following a fatty meal when cholecystokinin levels are highest + gallbladder contraction is maximal.
+/- N+V
Give a sign of biliary colic
RUQ pain or epigastric tenderness
Describe the nature of symptoms caused by gallstones
Most gallstones are asymptomatic
May lead to biliary colic
May lead to cholecystitis (inflam of gallbladder)
May lead to cholangitis (infect + inflam of bile duct)
Where may pain radiate in acute cholecystitis? What is this called?
Right shoulder (due to diaphragmatic irritation)
Boas sign
Give 2 risk factors for development of pigment stones
Haemolytic disorders e.g. SCA, thalassemia, hereditary spherocytosis
Severe cirrhosis
What bloods may be taken in suspected biliary colic?
FBC: normal
LFTs
Blood cultures
Amylase (r/o pancreatitis)
Describe investigations in biliary colic
Normal ALP + γGT
Normal AST + ALT
Normal CRP (not inflammatory)
What is the firstline investigation in suspected biliary colic? What may this show?
US of biliary tree
Shows gallstones
Increased thickness of gallbladder wall (>3mm); indicates cholecystitis
Dilatation of biliary tree indicative of obstruction
What is the treatment of choice for symptomatic cholelithiasis?
Analgesia +/- antispasmodic (hyoscine)
Laparoscopic Cholecystectomy
What is the conservative management approach to mild biliary colic? What may be arranged?
Analgesia
Low fat diet
Elective cholecystectomy
What is the treatment for symptomatic choledocolithiasis?
ERCP: stone extraction
May have elective cholecystectomy at a later date
List 4 complications of cholelithiasis
Biliary colic
Acute cholecystitis
Gallbladder empyema (abscess in gallbladder)
Gallbladder cancer (RARE)
List 3 main complications of stones outside the gallbladder
Acute pancreatitis
Ascending cholangitis
Obstructive jaundice
What is an uncommon complication of gallstones eroding through the gallbladder?
Fistula: causes pneumobilia (air in biliary tree + gallbladder on AXR) depending on fistula site:
Gallstone ileus (ileum ob)
Bouveret syndrome (duodenal ob)
Mirizzi syndrome (common hepatic duct / CBD ob)
Describe management of gallstone ileus
Laparotomy + removal of gallstone from small bowel, the enterotomy must be made proximal to site of obstruction + not at site of obstruction.
Fistula between gallbladder + duodenum should not be interfered with.
List 5 complications of cholecystectomy
Bleeding
Infection
Bile leak
Fat intolerance due to inability to secrete large amounts of bile into intestine
Post-cholecystectomy syndrome: abdo Sx e.g. dyspepsia, N+V, RUQ pain
Port-site hernia
What is the prognosis for gallstone disease?
Asymptomatic most of the time
Surgery curative in most cases if symptomatic
List 4 complications of ERCP
Bleeding 0.9% (1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Acute pancreatitis 1.5%
