Gallstones & biliary colic (GI) Flashcards
Define biliary colic.
Pain resulting from obstruction of the gallbladder or common bile duct, usually by a stone
Why does the pain in biliary colic occur?
Biliary tree is contracting to try and relieve obstruction
What are the 5Fs that are risk factors for gallstones?
- Fair (Caucasian)
- Fat
- Fertile
- Forty
- Female (increases oestrogen –> greater saturation)
What is the difference between cholelithiasis and choledocholithiasis (and biliary colic)?
- 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)
What are the types of gallstones? (3)
- cholesterol (80-90%)
- black pigment
- brown pigment
What are cholesterol gallstones made of?
- cholesterol and calcium carbonate
- supersaturation of bile with cholesterol
- accelerated cholesterol crystal nucleation
- gallbladder hypomotility
What are pigment gallstones (black/brown) associated with?
Haemolytic diseases like sickle cell anaemia
(black gallstones - cirrhosis, CF, ileal diseases)
(brown gallstones - bacterial infection, biliary parasites, stasis, biliary strictures)
What are pigment gallstones composed of?
Calcium bilirubinate due to increased unconjugated bilirubin
What are some risk factors for gallstones/biliary colic? (5 + 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
What are the clinical features of biliary colic? (8)
- 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
How do gallstones often present?
Asymptomatic
What are the first-line investigations for gallstones/biliary colic?
- abdominal USS
- serum LFTs
- FBC
- serum lipase or amylase
What might we see on abdominal USS in gallstones/biliary colic?
- visualise stones
- cholelithiasis - stones in GB
- choledocholithiasis - stones in bile duct with/without bile duct dilation
What other scan can we do for gallstones/biliary colic (after abdominal USS)?
MRCP - if US negative but common bile duct dilated, or normal LFTs, or EUS contraindicated
What are LFTs like in gallstones/biliary colic? (3)
- uncomplicated cholelithiasis - normal
- choledocholithiasis - elevated ALP + BR
- brief biliary obstruction with subsequent stone passage - early transient elevation in ALT before ALP rises
What would FBC show in gallstones/biliary colic?
- normal WBC in simple gallstones/biliary colic
- ddx: elevated WBC in acute cholecystitis, cholangitis or pancreatitis
Why do we measure serum lipase/amylase in gallstones/biliary colic?
Rule out acute pancreatitis if patient has epigastric pain (would be elevated 3x upper limit of normal in acute pancreatitis)
What are inflammatory markers like in gallstones/biliary colic?
No fever and inflammatory markers are normal
What are some differential diagnoses for gallstones/biliary colic? (6)
- 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
How do we manage asymptomatic cholelithiasis?
Nothing - observation if gallstones incidentally found in GB
When is prophylactic cholecystectomy done in cholelithiasis?
Only in those at risk of complications
What is the first-line management for symptomatic cholelithiasis?
- analgesia
- anti-spasmodic (hyoscine)
- IV fluids
- NBM
- elective laparoscopic cholecystectomy
What is the first-line management for choledocholithiasis?
- 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)
What is the definitive treatment for symptomatic cholelithiasis/choledocholithiasis?
Laparoscopic cholecystectomy
If ERCP is done first e.g. choledocholithiasis, subsequent lap chole is needed as definitive treatment
