General surgery - gallstones Flashcards
What are gallstones?
Made within the gallbladder
Most are made of cholesterol
Occur due to increased cholesterol, reduced bile salts and biliary stasis
Risk factors for gallstones
Four Fs:
- Fat
- Fair
- Female
- Forty
Also:
- DM
- Crohn’s
- Rapid weight loss e.g. weight reduction surgery
- Drugs - fibrates, COCP
Presentation of gallstones
Asymptomatic
Biliary colic
With complications such as cholecystitis, cholangitis, obstructive jaundice, pancreatitis
What is biliary colic presentation?
Severe colicky epigastric or RUQ pain
Often triggered by meals, particularly those high in fat
May be associated with nausea and vomiting
Why do fatty foods increase the biliary colic symptoms?
Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum.
CCK triggers contraction of the gallbladder, which leads to biliary colic.
Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.
Liver functions tests - bilirubin
Normally drains from the liver through the bile ducts and into the intestines
Raised bilirubin (jaundice) with pale stools and dark urine represents an obstruction to flow within the biliary system.
Liver function tests - ALP and causes of raised ALP
A non-specific marker
An enzyme originating in the liver, biliary system and bone, and abnormal results can indicate liver or bone problems.
Also often raised in pregnancy due to production by the placenta
Raised ALP:
- Biliary obstruction (in presence of RUQ pain and/or jaundice
- Liver malignancy
- Bone malignancy
- Primary biliary cirrhosis
- Paget’s disease of the bone
Liver function tests - aminotransferases
ALT and AST - enzymes produced by the liver
Useful markers of hepatocellular injury
Hepatic vs Cholestatic picture LFTs
Hepatic - ALT and AST more markedly raised than ALP
Cholestatic - ALP has a higher rise
First line investigation for gallstone disease
Ultrasound scan - can identify:
- Presence of gallstones
- Bile duct dilatation
- Cholecystitis - thickened gallbladder wall
- Pancreas and pancreatic duct
Other investigations in gallstone disease
MRCP - MRI that produces detailed images of the biliary system
Typically this is used to investigate further if the ultrasound scan doesn’t show stones in the duct, but there is bile duct dilatation or raised bilirubin suggestive of obstruction.
What can be the management of gallstones?
Asymptomatic patients with gallstones - may not need intervention
Lap chole for patients with symptoms of gallstones (biliary colic) or complications of gallstones
ERCP - indicated for removal of stones in the bile ducts, can also stent duct to improve drainage and biopsy any tumours
How is ERCP performed?
Endoscope down the oesophagus, through the stomach, duodenum and into the opening of the common bile duct (Sphincter of Oddi)
Complications of ERCP
Excessive bleeding
Cholangitis
Pancreatitis
Possible complications of gallstones other than biliary colic
acute cholecystitis: the most common complication
ascending cholangitis
acute pancreatitis
gallstone ileus
gallbladder cancer
