Gallstones + Biliary Colic

Question 1

What is Cholelithiathis?

Answer 1

presence of solid deposits (stones) in the gallbladder.

Question 2

What is Choledocoliathisis?

Answer 2

Gallstones in the CBD

Question 3

What is acute cholecystitis?

Answer 3

Acute inflammation of the gallbladder
Typically due to cystic duct obstruction by a gallstone

Question 4

What is ascending cholangitis?

Answer 4

Ascending bacterial infection of biliary tract facilitated by bile stasis
Caused by combination of biliary outflow obstruction + biliary infection

Question 5

What is Biliary Colic?

Answer 5

RUQ pain caused by gallbladder, cystic duct or CBD contracting around a gallstone
Most common complication of gallstones

Question 6

List the 3 types of gallstone

Answer 6

Pure Cholesterol Stones: MOST COMMON
Mixed stones
Pigment Stones

Question 7

Describe pigment stones

Answer 7

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

Question 8

Describe mixed stones

Answer 8

Contain cholesterol, calcium bilirubinate, phosphate + protein
Form due to imbalance between bile salts, phospholipids, cholesterol, nucleation factors + gallbladder motility

Question 9

Describe the epidemiology of gallstones

Answer 9

Very COMMON
UK prevalence of gallstone disease = 10-15% (only 1-2% become symptomatic)
F > M in younger population
More common with increasing age

Question 10

List 5 F’s and 2 additional risk factors for gallstones

Answer 10

Female (oestrogen increases risk)
Fertile/ pregnant (oestrogen increases risk + HRT)
40 (increases with age)
Fat
FH
Diabetes mellitus
Drugs (OCP, octreotide)

Question 11

What is the classical presenting complaint of biliary colic?

Answer 11

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

Question 12

Give a sign of biliary colic

Answer 12

RUQ pain or epigastric tenderness

Question 13

Describe the nature of symptoms caused by gallstones

Answer 13

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)

Question 14

Where may pain radiate in acute cholecystitis? What is this called?

Answer 14

Right shoulder (due to diaphragmatic irritation)
Boas sign

Question 15

Give 2 risk factors for development of pigment stones

Answer 15

Haemolytic disorders e.g. SCA, thalassemia, hereditary spherocytosis
Severe cirrhosis

Question 16

What bloods may be taken in suspected biliary colic?

Answer 16

FBC: normal
LFTs
Blood cultures
Amylase (r/o pancreatitis)

Question 17

Describe investigations in biliary colic

Answer 17

Normal ALP + γGT
Normal AST + ALT
Normal CRP (not inflammatory)

Question 18

What is the firstline investigation in suspected biliary colic? What may this show?

Answer 18

US of biliary tree
Shows gallstones
Increased thickness of gallbladder wall (>3mm); indicates cholecystitis
Dilatation of biliary tree indicative of obstruction

Question 19

What is the treatment of choice for symptomatic cholelithiasis?

Answer 19

Analgesia +/- antispasmodic (hyoscine)
Laparoscopic Cholecystectomy

Question 20

What is the conservative management approach to mild biliary colic? What may be arranged?

Answer 20

Analgesia
Low fat diet
Elective cholecystectomy

Question 21

What is the treatment for symptomatic choledocolithiasis?

Answer 21

ERCP: stone extraction
May have elective cholecystectomy at a later date

Question 22

List 4 complications of cholelithiasis

Answer 22

Biliary colic
Acute cholecystitis
Gallbladder empyema (abscess in gallbladder)
Gallbladder cancer (RARE)

Question 23

List 3 main complications of stones outside the gallbladder

Answer 23

Acute pancreatitis
Ascending cholangitis
Obstructive jaundice

Question 24

What is an uncommon complication of gallstones eroding through the gallbladder?

Answer 24

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)

Question 25

Describe management of gallstone ileus

Answer 25

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.

Question 26

List 5 complications of cholecystectomy

Answer 26

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

Question 27

What is the prognosis for gallstone disease?

Answer 27

Asymptomatic most of the time
Surgery curative in most cases if symptomatic

Question 28

List 4 complications of ERCP

Answer 28

Bleeding 0.9% (1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Acute pancreatitis 1.5%