Gallstones & biliary colic (GI)

Question 1

Define biliary colic.

Answer 1

Pain resulting from obstruction of the gallbladder or common bile duct, usually by a stone

Question 2

Why does the pain in biliary colic occur?

Answer 2

Biliary tree is contracting to try and relieve obstruction

Question 3

What are the 5Fs that are risk factors for gallstones?

Answer 3

• Fair (Caucasian)
• Fat
• Fertile
• Forty
• Female (increases oestrogen –> greater saturation)

Question 4

What is the difference between cholelithiasis and choledocholithiasis (and biliary colic)?

Answer 4

• cholelithiasis - gallstones in gallbladder
• choledocholithiasis - gallstones in bile ducts
• (biliary colic - pain caused by GB muscle spasms driven by gallstone in neck of GB/cystic duct - stone itself does not cause pain)

Question 5

What are the types of gallstones? (3)

Answer 5

• cholesterol (80-90%)
• black pigment
• brown pigment

Question 6

What are cholesterol gallstones made of?

Answer 6

• cholesterol and calcium carbonate
• supersaturation of bile with cholesterol
• accelerated cholesterol crystal nucleation
• gallbladder hypomotility

Question 7

What are pigment gallstones (black/brown) associated with?

Answer 7

Haemolytic diseases like sickle cell anaemia

(black gallstones - cirrhosis, CF, ileal diseases)

(brown gallstones - bacterial infection, biliary parasites, stasis, biliary strictures)

Question 8

What are pigment gallstones composed of?

Answer 8

Calcium bilirubinate due to increased unconjugated bilirubin

Question 9

What are some risk factors for gallstones/biliary colic? (5 + 9)

Answer 9

• 5Fs: Fair, Fat, Fertile, Female, Forty
• OCP
• sickle cell anaemia (haemolytic conditions = BR breakdown)
• rapid weight loss (after bariatric surgery)
• total parenteral nutrition
• non-alcoholic liver disease
• terminal ileum disease/resection e.g. Crohn’s (bile salt malabsorption –> bile overly saturated with cholesterol = cholesterol stones)
• low fibre diet
• H. pylori infection
• Native America/Hispanic ethnicity

Question 10

What are the clinical features of biliary colic? (8)

Answer 10

• RUQ (or epigastric) pain >30 mins
  
  • postprandial pain - colicky pain 1h after ingestion of fatty meal
  • pain may radiate to right scapula
  • increases intensity –> constant for hours –> subsides
  • responds to analgesia
• nausea and vomiting
• jaundice
• Murphy’s sign negative

Question 11

How do gallstones often present?

Answer 11

Asymptomatic

Question 12

What are the first-line investigations for gallstones/biliary colic?

Answer 12

• abdominal USS
• serum LFTs
• FBC
• serum lipase or amylase

Question 13

What might we see on abdominal USS in gallstones/biliary colic?

Answer 13

• visualise stones
• cholelithiasis - stones in GB
• choledocholithiasis - stones in bile duct with/without bile duct dilation

Question 14

What other scan can we do for gallstones/biliary colic (after abdominal USS)?

Answer 14

MRCP - if US negative but common bile duct dilated, or normal LFTs, or EUS contraindicated

Question 15

What are LFTs like in gallstones/biliary colic? (3)

Answer 15

• uncomplicated cholelithiasis - normal
• choledocholithiasis - elevated ALP + BR
• brief biliary obstruction with subsequent stone passage - early transient elevation in ALT before ALP rises

Question 16

What would FBC show in gallstones/biliary colic?

Answer 16

• normal WBC in simple gallstones/biliary colic
• ddx: elevated WBC in acute cholecystitis, cholangitis or pancreatitis

Question 17

Why do we measure serum lipase/amylase in gallstones/biliary colic?

Answer 17

Rule out acute pancreatitis if patient has epigastric pain (would be elevated 3x upper limit of normal in acute pancreatitis)

Question 18

What are inflammatory markers like in gallstones/biliary colic?

Answer 18

No fever and inflammatory markers are normal

Question 19

What are some differential diagnoses for gallstones/biliary colic? (6)

Answer 19

• peptic ulcer disease - burning pain in upper abdomen with food, improved by antacids
• gallbladder cancer - painless jaundice
• gallbladder polyps
• acalculous cholecystitis - positive Murphy’s sign (inspiratory arrest on palpation)
• sphincter of Oddi dysfunction
• non-biliary acute pancreatitis

Question 20

How do we manage asymptomatic cholelithiasis?

Answer 20

Nothing - observation if gallstones incidentally found in GB

Question 21

When is prophylactic cholecystectomy done in cholelithiasis?

Answer 21

Only in those at risk of complications

Question 22

What is the first-line management for symptomatic cholelithiasis?

Answer 22

• analgesia
• anti-spasmodic (hyoscine)
• IV fluids
• NBM
• elective laparoscopic cholecystectomy

Question 23

What is the first-line management for choledocholithiasis?

Answer 23

• bile duct clearance - ERCP with biliary sphincterotomy and stone extraction OR surgically with laparoscopic CBD exploration
• analgesia
• anti-spasmodic
• (2nd line - temporary stenting prior to definitive biliary clearance)

Question 24

What is the definitive treatment for symptomatic cholelithiasis/choledocholithiasis?

Answer 24

Laparoscopic cholecystectomy

If ERCP is done first e.g. choledocholithiasis, subsequent lap chole is needed as definitive treatment

Question 25

What are some complications of gallstones/biliary colic? (8)

Answer 25

• acute cholecystitis
• ascending cholangitis
• acute pancreatitis
• gallstone ileus (detected by pneumobilia - air in biliary tree on CXR + SBO)
• gallbladder cancer
• Bouveret syndrome –> fistula
• Mirizzi syndrome - gallstone lodged in cystic duct and damage common hepatic duct = biliary obstruction and jaundice
• cholecystectomy risks - bile leak, fat intolerance (no longer secretes bile to digest fat), post-cholecystectomy syndrome, hernia