GI - Gallstones And Billiary Colic

Question 1

Gallstones: epidemiology

Answer 1

• Fat, female, fertile and forty
• Approx 8% of pop suffers from gallstones
• raised incidence in last 20 years - western diet
• 90% gallstones remain asymptomatic

Question 2

Gallstones: formation - general composition

Answer 2

• Phospholipids
• Bile pigments (broken down Hb)
• Cholesterol

Question 3

Gallstones: formation -aetiology

Answer 3

• Lithogenic bile: bile that favours production of gallstones (usually associated with increased secretion of cholesterol in the bile due in obesity/high calorie diets, etc)
• Biliary sepsis
• Gall bladder hypomotility (stasis): seen in pregnancy, OCP, fasting, TPN,

Question 4

Describe cholesterol stones

Answer 4

• 20% of stones: large and often solitary
• Formation increases according to Admirand’s triangle (less bile salts and lecithin and raised cholesterol)
• Risk factors: female, OCP/pregnancy, high fat diet/obesity, loss of terminal ileum (loss of bile salts)

Question 5

Describe pigment stones

Answer 5

• 5% of stones: small, black, gritty and fragile

- Calcium bilirubinate - associated with haemolysis

Question 6

Describe mixed stones

Answer 6

• 75% of stones
• Often multiple
• cholesterol is main component

Question 7

Gallstones: complications - in gallbladder

Answer 7

• biliary colic: pain when gallstone blocks cystic duct
• Acute cholecystitis: inflammation of gallbladder
• Chronic cholecystitis: caused by mechanical or functional dysfunction of emptying of gallbladder
• Mucocele
• Carcinoma
• Mirizzi syndrome: stone trapped in cystic duct but compresses on CBD (looks like obstructive picture)

Question 8

Gallstones: complications - in CBD

Answer 8

• Obstructive jaundice
• pancreatitis
• cholangitis
• choledocholithiasis

Question 9

Gallstones: complications - in gut

Answer 9

-gallstone ileus: small bowel obstruction caused by impaction of gallstone within lumen of small intestine - enters bowel via cholecysto-enteric fistula

Question 10

Biliary colic: pathogenesis

Answer 10

• Gallbladder spasm against a stone impacted in neck of gallbladder (Hartmann’s pouch)
• less common: stone in CBD

Question 11

Biliary colic: presentation

Answer 11

• Biliary colic (pt moves to try to get comfortable)
• RUQ: pain radiating to the back (scapular region)
• Attacks may be precipitated by fatty food and last <6h
• O/E: tenderness in right hypochondrium
• +/- jaundice if stone passes in CBD

Question 12

Biliary colic: differential

Answer 12

• Cholecystitis/other gallstone disease
• pancreatitis
• bowel perforation

Question 13

Biliary colic: Ix. (Not including imaging)

Answer 13

• Same work up as cholecystitis as may be difficult to differentiate clinically
• Urine: bilirubin/urobilinogen and Hb
• Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP

Question 14

Biliary colic: Ix - imaging

Answer 14

• AXR: 10% of are radio-opaque
• Erect CXR: look for perf
• US: stones (acoustic shadow), dilated ducts (>6mm), inflamed GB (wall oedema)
• If Dx uncertain after US: can do MRCP

Question 15

Biliary colic: Rx - conservative

Answer 15

• Rehydrate and NBM
• Opioid analgesia: morphine 5-10mg
• High recurrence rate: t/f surgical rx is favoured

Question 16

Biliary colic: Rx - surgical

Answer 16

Conservative + either:

• Urgent laparoscopic cholecystectomy (same admission)
• Elective laparoscopic cholecystectomy at 6-12 week