Gallstones + Biliary Colic

Question 1

What are Gallstones?

Answer 1

Stone formation in the gall bladder

Question 2

What is Biliary Colic?

Answer 2

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.

Question 3

What is Cholelithiathis?

Answer 3

Gallstones in the gallbladder

Question 4

What is Choledocoliathisis?

Answer 4

Gallstones in the CBD

Question 5

What is acute cholecystitis?

Answer 5

Acute inflammation of the gallbladder

Typically due to cystic duct obstruction by a gallstone

Question 6

What is ascending cholangitis?

Answer 6

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

Question 7

Describe the aetiology of biliary colic

Answer 7

Biliary colic occurs due to the contractions of the biliary tree to relieve an obstruction

Question 8

List the 3 types of gallstone

Answer 8

Pure Cholesterol Stones: MOST COMMON
Mixed stones
Pigment Stones

Question 9

Describe pigment stones

Answer 9

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

Question 10

Describe mixed stones

Answer 10

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

Question 11

Describe the epidemiology of gallstones

Answer 11

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 12

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

Answer 12

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

Question 13

List 5 features/ symptoms of biliary colic

Answer 13

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

Question 14

List 6 signs of acute cholecystitis

Answer 14

Murphy’s sign positive
Boas sign positive (diaphragm irritation referred)
Tachycardia
Pyrexia
Local peritonism; guarding +/- rebound tenderness
RUQ pain or epigastric tenderness

Question 15

Describe the nature of symptoms caused by gallstones

Answer 15

Most gallstones are asymptomatic
May lead to cholecystitis (inf + inflam of gallbladder)
May lead to ascending cholangitis (inflam of bile duct)

Question 16

Give 2 symptoms of acute cholecystitis

Answer 16

Systemically unwell e.g. Fever

Prolonged upper abdo pain >5 hours

Question 17

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

Answer 17

Right shoulder (due to diaphragmatic irritation)
Boas sign

Question 18

Give 2 risk factors for development of pigment stones

Answer 18

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

Question 19

What bloods may be taken in suspected gallstone disease?

Answer 19

FBC: WCC + CRP HIGH
LFT: high ALP (cholangiocytes damaged) + GGT in ascending cholangitis
Blood cultures
Amylase (exclude pancreatitis)

Question 20

What is the gold standard investigation in gallstone disease? What may this show?

Answer 20

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

Question 21

What is the treatment of choice for symptomatic cholelithiasis?

Answer 21

Laparoscopic Cholecystectomy

Question 22

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

Answer 22

Analgesia
Low fat diet
Elective cholecystectomy

Question 23

What is the treatment for symptomatic choledocolithiasis?

Answer 23

MRCP: For better visualisation to locate stones
ERCP: Endoscopy tube to remove stones
May have elective cholecystectomy at a later date

Question 24

List 4 complications of cholelithiasis

Answer 24

Biliary colic
Cholecystitis
Gallbladder empyema (abscess in gallbladder)
Gallbladder cancer (RARE)

Question 25

List 3 main complications of stones outside the gallbladder (+4 others)

Answer 25

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)

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

Describe the treatment of acute cholecystitis

Answer 28

Sepsis 6 protocol

Urgent Cholecystectomy

Question 29

Describe the treatment of ascending cholangitis

Answer 29

Sepsis 6 protocol

Biliary decompression