Gallstones + Biliary Colic Flashcards
What are Gallstones?
Stone formation in the gall bladder
What is Biliary Colic?
RUQ or epigastric tenderness due to an obstruction of the gallbladder or CBD usually due to a gallstone
Pain can be poorly localised due to its visceral nature.
What is Cholelithiathis?
Gallstones 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
Describe the aetiology of biliary colic
Biliary colic occurs due to the contractions of the biliary tree to relieve an obstruction
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 bile duct infestation by liver fluke Clonorchis sinensis
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 (oestrogen increases risk + HRT) 40 (increases with age) Fat FH Diabetes mellitus Drugs (OCP, octreotide)
List 5 features/ symptoms of biliary colic
Sudden onset, severe RUQ or epigastric pain Constant pain 30mins-hours May radiate to right scapula Often precipitated by a fatty meal. May be associated with N+V
List 6 signs of acute cholecystitis
Murphy’s sign positive
Boas sign positive (diaphragm irritation referred)
Tachycardia
Pyrexia
Local peritonism; guarding +/- rebound tenderness
RUQ pain or epigastric tenderness
Describe the nature of symptoms caused by gallstones
Most gallstones are asymptomatic
May lead to cholecystitis (inf + inflam of gallbladder)
May lead to ascending cholangitis (inflam of bile duct)
Give 2 symptoms of acute cholecystitis
Systemically unwell e.g. Fever
Prolonged upper abdo pain >5 hours
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 gallstone disease?
FBC: WCC + CRP HIGH
LFT: high ALP (cholangiocytes damaged) + GGT in ascending cholangitis
Blood cultures
Amylase (exclude pancreatitis)
What is the gold standard investigation in gallstone disease? 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?
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?
MRCP: For better visualisation to locate stones
ERCP: Endoscopy tube to remove stones
May have elective cholecystectomy at a later date
List 4 complications of cholelithiasis
Biliary colic
Cholecystitis
Gallbladder empyema (abscess in gallbladder)
Gallbladder cancer (RARE)
List 3 main complications of stones outside the gallbladder (+4 others)
Pancreatitis
Ascending cholangitis
Obstructive jaundice
Cholecystoduodenal fistula: causes pneumobilia (air in biliary tree + gallbladder on AXR)
Gallstone ileus
Bouveret syndrome (gallstones cause gastric outlet ob)
Mirizzi syndrome (common hepatic duct ob)
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
Describe the treatment of acute cholecystitis
Sepsis 6 protocol
Urgent Cholecystectomy
Describe the treatment of ascending cholangitis
Sepsis 6 protocol
Biliary decompression
