Gallstones (cholelithiasis + choledocholithiasis) Flashcards
What different kinds of gallstones can be formed from the various bile components?
- Cholesterol stones (>80%)
- Pigment salt stones (calcium) bile salts
- Mixed
Risk factors for cholesterol stones
4Fs = fat, forty, female, fertile (oestrogens)
- diet
- impaired GB emptying (TPN, DM…)
- rapid weight loss (cholesterol liberated from fat stores)
- terminal ileal resection/disease
Admirand’s triangle = high risk of gallstones if:
- ↓lecithin
- ↓bile salts
- ↑cholesterol
Risk factor for pigment stones
haemolysis
Standard tests ordered in suspected biliary pain?
- Standard bloods (FBE, UEC, LFTs, lipase)
- U/S
- ERCP
- MRCP
- PTC (percutaneous transhepatic cholangiography)
- HIDA scan
define:
(1) cholelithiasis
(2) biliary colic
(3) acute cholecystitis
(4) chronic cholecystitis
(5) acalculous cholecystitis
(6) choledocholithiasis
(7) cholangitis
(1) stones in GB
(2) stones transiently in cystic duct (no infx)
(3) GB inflammation due to prolonged stone impaction in cystic duct
(4) longstanding GB inflammation
(5) GB inflammation w/o stone (usually ischemic/stasis)
(6) stones in the CBD
(7) infx/inflammation of biliary tree
What % gallstones (cholelithiasis) are asymptomatic?
> 80%
Risk factors for symptoms (2)
smoking
parity
Biliary colic Px
- constant epigrastric/RUQ pain lasting mis-hours (may radiate to back/shoulder, associated w. food, esp. fatty meals, often at night)
- pts often restless
- no peritoneal involvement
(may px as chest pain)
How is biliary colic Dx?
Normal bloods
U/S shows cholelithiasis (+/- stone)
How is it Rx?
Analgesia
Rehydration
Often self-resolving
+/- elective cholecystectomy
Acute cholecystitis clinical Px
- constant epigrastric/RUQ pain lasting lasting hours-days
- peritoneal signs (Murphey’s sign)
- Systemic signs (anorexia, N/V, low grade fever)
- may have Hx biliary colic
- may feel inflamed phegmon
Acute cholecystitis clinical Px
- constant epigrastric/RUQ pain lasting lasting hours-days
- peritoneal signs (Murphey’s sign)
- Systemic signs (anorexia, N/V, low grade fever)
- may have Hx biliary colic
- may feel inflamed phlegmon
Acute cholecystitis Dx
- Standard bloods (leukocytosis, elevated bili/AST/ALT/ALP)
- US (thick wall, shrunken GB, pericholecystic fluid, stones, CBD > 6mm)
- Consider HIDA if -ve US
Acute cholecystitis Rx
- Analgesia
- Hydration
- Abx (cephzolin)
- Consider cholecystectomy
Acute cholecystitis Cx
- GB empyema
- GB mucocele (after cystic duct obstruction)
- Gangrene / perforation
- Cholecystenteric fistula (–> gallstone ileus)
- Emphysematous cholecystitis (gas produced by bacteria)
- Mirizzi syndrome (large stone in cystic duct –> compresses CBD/CHD)
Cx cholecystectomy
- pancreatitis
- CBD injury
- bile peritonitis
- hollow viscus/vessel injury
Cx cholecystectomy
- pancreatitis
- CBD injury
- bile peritonitis
- hollow viscus/vessel injury
Chronic cholecystitis clinical px
- Flatulant dyspepsia
- Vague abdominal discomfort
- Distention, N/V, fat intolerance
Chronic cholecystitis Dx
US/MRCP = stones
US = CBD > 6mm
ERCP + sphincterotomy = before surgery
Chronic cholecystitis Rx
Cholecystectomy
Acalculous cholecystectomy Px
- Most asymptomatic
- As acute cholecystitis
(biliary pain for hours-days, anorexia, N/V, low-grade fever +/- inflamed phlegmon)
Acalculous cholecystctomy Rx
Broad spectrum ABX
Cholecystectomy
Choledocholithiasis clinical px
- 50% asymptomatic
- biliary pain (usually no radiation to shoulder)
- alcoholic stool
- obstructive jaundice
