Gallstones & Biliary Colic

Question 1

What are gallstones?

Answer 1

Stones forming in the gallbladder, typically of mixed composition or cholesterol.

Question 2

What diseases can gallstones lead onto? (8)

Answer 2

Biliary Colic
Acute Cholecystitis
Gallbladder Abscess
(Ascending) Cholangitis
Acute Pancreatitis
Gallstone Ileus
Acalculous Cholesystitis
Gallbladder Cancer

Question 3

What is the most common disease caused by gallstones?

Answer 3

Cholecystitis

Question 4

What is the epidemiology of gallstones?

Answer 4

Women (24%) > Men (12%)

Question 5

What is the most common location of gallstones?

Answer 5

Common bile duct

Can be migratory or de novo

Question 6

What disease occurs when gallstones are trapped in the common bile duct?

Answer 6

Biliary Colic

Question 7

What are the classical symptoms of biliary colic?

Answer 7

Colicky right upper quadrant pain that occurs postprandially
Worse following fatty meals
Pain may radiate to the right shoulder/interscapular region
Nausea and vomiting are common

Question 8

What are the investigations for gallstones?

Answer 8

Abdominal ultrasound
Liver function tests
(60% one abnormal LFT)

Where stones are suspected in the bile duct the options lie between magnetic resonance cholangiography (MRCP) and intraoperative imaging.

Question 9

What is the treatment of gallstones?

Answer 9

Asymptomatic - common, treatment not required, only 2% progress

If in common bile duct increased risk of cholangitis and pancreatitis and surgery should be considered

Laparoscopic cholecystectomy + intraoperative cholangiography
(Frail - cholecystostomy)

If common bile duct stones are found - early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct.

Small stones <5mm will mostly pass spontaneously.

Question 10

What are the risks of ERCP?

Answer 10

Bleeding 0.9%
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 1.5%

Question 11

What causes biliary colic?

Answer 11

Gallstones passing through the biliary tree

Question 12

What are the risk factors for gallstones/biliary colic?

Answer 12

'4 Fs'
Fat - increased cholesterol
Female - 2-3 x more common, oestrogen related
Fertile - Pregnancy risk factor
Forty - Age

Question 13

What other diseases are risk factors for gallstones/biliary colic?

Answer 13

Diabetes mellitus
Crohn’s disease
Rapid weight loss e.g. weight reduction surgery
Drugs: Fibrates, COCP

Question 14

What is the pathophysiology of gallstone formation?

Answer 14

Increased cholesterol
Reduced bile salts
Biliary stasis

Question 15

What causes the pain in biliary colic?

Answer 15

Due to the gallbladder contracting against a stone lodged in the cystic duct

Question 16

What is the name of gallstones in the common bile duct and what condition can this cause?

Answer 16

Choledocholithiasis

Obstructive jaundice in some patients

Question 17

What is gallstone ileus?

Answer 17

Small bowel obstruction secondary to an impacted gallstone
It may develop if a fistula forms between a gangrenous gallbladder and the duodenum
Abdominal pain, distension and vomiting are seen

Question 18

What is acalculous cholecystitis?

Answer 18

Cholecystitis seen without gallstones, in patients with recurrent severe illness
Very ill - poor prognosis

Question 19

What is the treatment of acalculous cholecystitis?

Answer 19

Cholecystectomy or percutaneous cholecystostomy