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GI Week 4 > ICL 6.2: Gallstones > Flashcards

ICL 6.2: Gallstones Flashcards

1
Q

what populations are more often effected by gallstones?

A

gallstones are one of the most prevalent and costly digestive diseases in western countries

12% of US population have gallstones with 1000,000 new cases/year (Increases with age).

it’s double in women (20-40%) than in men (10-15% of men)

an estimated 700,000 cholecystectomies/year

medical expenses exceeded $6 billion in year

common in Pima Indians/ rare in Eskimo

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2
Q

what are the 3 types of gallstones?

A
  1. cholesterol stones

pure and mixed cholesterols stones = 75% of gallstones

  1. pigmented stones

black stones (20%) and brown stones (4.5%)

  1. calcium stones; super rare
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3
Q

what are cholesterol gallstones?

A

most common type of gallstones in US (∼75%)

PURE cholesterol vs. MIXED (contain at least 50% cholesterol by weight).

consist of: cholesterol monohydrate crystals & precipitates of amorphous calcium bilirubinate, with calcium carbonate or phosphate in one of the crystalline polymorphs.

most of gallstones are “SILENT” & 1/3 cause symptoms & complications.

complications of gallstones result in 3000 deaths/year

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4
Q

what type of gallstones do Crohn’s patients have?

A

the bile acid is formed in the hepatocytes and secreted into the biliary tree

then it collects in the gallbladder when someone isn’t eating – when they eat the bile will get pushed to the duodenum and then the ileum –> the ileum is where bile acids get reabsorbed!!

that’s why Crohn’s of the ileum has higher cholesterol stone formation

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5
Q

how are cholesterol gallstones formed?

A
  1. cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts
  2. incomplete and infrequent emptying of the gallbladder may case the bile to become over concentrated and contribute to gallstone formation
  3. increased levels of the hormone estrogen

hypercholesterolemia in the blood doesn’t have anything to do with gallstones!! it’s just high cholesterol in the bile!! it has nothing to do with serum levels of cholesterol

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6
Q

what is the pathophysiology of cholesterol gallstones?

A

at least five primary defects must be present simultaneously for cholesterol gallstone formation:

  1. genetic factors causing hyper secretion of cholesterol in the bile; when there’s more cholesterol than bile salts they’ll accumulate and you’ll get a stone
  2. hyper motility of gallbladder
  3. rapid phase transitions
  4. hepatic hyper secretion
  5. intestinal factors
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7
Q

what is the difference between pure and mixed cholesterol gallstones?

A

PURE
1. large and yellow/white color

  1. composed purely or mainly of cholesterol

MIXED
1. multiple and smaller

  1. composed of 50%+ of cholesterol
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8
Q

which enzyme deficiency is related to cholesterol stones in pregnancy?

A

cholesterol 7 alpha-hydroxylate

deficiency of this means deficiency in bile salts which will lead to saturated bile with cholesterol!

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9
Q

what are the risks for cholesterol gallstone formation?

A
  1. age ( 50’s and 60’s ).
  2. female.
  3. obesity: increase cholesterol synthesis & excretion.
  4. weight loss
  5. TPN or any prolonged fasting state means the gallbladder won’t contract and the bile will get thick and form stones
  6. pregnancy ( more in multiparous).
  7. drugs: (Estrogen, Progesterone, Fibrate Birth control pills, Octreotide)
  8. genetic predisposition (i.e. Native American )
  9. terminal ileum disease like in Crohn’s (reduces bile acid pool)
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10
Q

what are the risk factors for a black pigmented stone?

A

they’re do to hemolysis aka destruction of RBCs!!

  1. female
  2. not associated with obesity
  3. older age
  4. chronic hemolysis like in SC disease or hereditary spherocytosis
  5. liver cirrhosis
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11
Q

what are the risk factors for a brown pigmented stone?

A

more cholesterol than black pigment stones; somewhat amenable to

CBD stone type > 2 years post cholecystectomy

common in asia

risks:
1. stasis

  1. infection (e. coli)
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12
Q

what imaging can you do to diagnose gallstone?

A
  1. ultrasound (ALWAYS must order because it’s safe, cheap and easy to do)
  2. MRCP
  3. EUS
  4. HIDA scan
  5. ERCP
  6. IOC
  7. CT scan
  8. MRI
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13
Q

if you’re looking for a stone in the gallbladder, what imagining is best?

A

ultrasoun

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14
Q

what is ultrasound imagining used for?

A
  1. cholelithiasis > 95% accurate = stone in gallbladder
  2. choledocholethiasis = 50% accurate
  3. acute cholecystitis >90%
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15
Q

what is MRCP imaging used for?

A

choledocholethiasis

best stone to look for common bile duct stone; EUS if contraindicated

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16
Q

what is EUS imaging used for?

A

choledocholethiasis

stone in the bile duct but it’s minimally invasive so MRCP is better if you can do that

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17
Q

what is HIDA scan imaging used for?

A

acute cholecystitis = 95% accurate

this is the most specific test for cholysystitis, not the most sensitive; that’s US

18
Q

what is ERCP imaging used for?

A

choledocholestiasis = 95% acurate

this is NOT a diagnostic test! ERCP is a therapeutic test, not diagnostic

19
Q

what is CT/MRI imaging used for?

A

complications

can show stones in the gallbladder but it’s not good for looking at stones in bile duct

ex. if someone has pancreatitis from gallstones; not used just to look at stones

20
Q

what is an intraoperative cholangiogram?

A

sometimes we dont know there’s a bile duct stone but we know there’s gallbladder stones

if there’s abnormal liver function tests this means there might be a stone in the bile duct – if the stones are just in the gallbladder even with cholocystits, liver function is normal because the drainage from the liver is still fine

so an IOC is used to look for bile duct stone

21
Q

what is complicated gallstone disease?

A
  1. aute cholecystitis
  2. choledocholethiasis –> biliary colic, acute cholangitis, acute pancreatitis
  3. Mirizzi syndrome
  4. gallstone ileus
22
Q

what is biliary colic?

A

intermittent blockage of biliary duct or cystic duct presenting with classic symptom of gallstone

intermittent obstruction of the cystic duct (NL LFTs)

severe epigastric or RUQ pain that:
1. lasts for < 6hrs

  1. may radiate to the shoulder blades
  2. may be post-prandial
  3. may associate with nausea or vomiting

classic history: intermittent attacks with pain-free periods between attacks

23
Q

what is Mirizzi syndrome?

A

gallstone in the cystic duct and pressing on the bile duct without being completely in the bile duct

stone in cystic duct compressing or fistulaizing on the bile duct

obstruction of the common hepatic duct by an extrinsic compression from an impacted stone in the cystic duct or Hartmann’s pouch of the gallbladder.

symptoms can be jaundice, fever, right upper quadrant pain

24
Q

how do you treat asymptomatic gallbladder stones?

A

risk of symptoms or complications is <1% per year

NO intervention (i.e. no surgery)  
Educate about potential development of symptoms
25
Q

what can cause symptomatic uncomplicated gallbladder stones?

A
  1. biliary sludge

2. biliary colic

26
Q

what is gallbladder sludge?

A

a collection of crystals and mucous that is the precursor of gallstones

it usually disappears spontaneously

may cause the same symptoms as sonnets!

US diagnosis

27
Q

how do you treat biliary colic?

A

cholecystectomy = remove gallbladder

risk of further symptoms or complications is 40% within 1 year & 70% within 2 years if you don’t remove it!

28
Q

what are the complications of gallstones?

A
  1. acute cholecystitis
  2. Mirizzi syndrome
  3. choledocholithiasis: Biliary colic, cholangitis and pancreatitis
  4. gallstone Ileus
  5. gallbladder carcinoma
29
Q

what is acute cholecystitis caused by a gallstone?

A

a stone is impacted in the cystic duct causing acute cholecystitis; diagnose with UT or HIDA scan

  1. acute calculous cholecystitis (95%):

continued obstruction of the cystic duct by a stone

persistent RUD/Epigastric abdominal pain

LFTs are usually normal (or slightly elevated < X2)

mortality rate is 5-10% in patients > 60 year-old with serious associated diseases

  1. acute acalculous cholecystitis (5%):

hospitalized patients with prolonged fasting: trauma, surgery or TPN

pathogenesis: Unknown. ? gallbladder ischemia or ? cystic duct occlusion by inspissated bile

30
Q

how do you treat acute cholecystitis?

A

laparoscopic cholecystectomy

31
Q

what are the complications of acute cholecystitis?

A
  1. infection (emphysematous gallbladder or empyema)
  2. perforation: abscesses and generalized peritonitis
  3. fistula formation: fallbladder to the duodenum, colon, stomach, and jejunum.
32
Q

what are the symptoms of chronic cholecystitis?

A

no fever or high WBC

when they eat there’s pain

HIDA scan will be positive just like in acute

33
Q

what is choledocholithiasis?

A

stone in the bile duct

symptoms: Biliary colic, biliary obstruction

diagnostic images:
1. high probability: ERCP

  1. moderate probability: MRCP/EUS
  2. low probability: Lap chole + IOC
    complications: ascending cholangitis and pancreatitis
    treatment: ERCP and sphincterotomy, > 90% successful stone removal – treat even if there aren’t symptoms!!
34
Q

what are the complications of choledocholiathiasis?

A
  1. biliary colic
  2. ascending cholangitis (infection in the bile duct)
  3. pancreatitis

asymptomatic choledocholiathiasis you must remove gallbladder with cholesystectomy and remove stone from bile duct with ERCP

35
Q

what are the clinical manifestations of acute cholangitis?

A

Impacted stone in the bile duct (infection)

  1. Charcot’s triad: 70% (fever, pain, jaundice)
  2. Reynold’s Pentad:
    • Charcot’s triad plus (Confusion & hypotension)
  3. Labs: Elevated WBC & LFTs, (+) blood culture

Dx tests: US, CT scan, MRCP, ERCP

Tx: - Emergency ERCP to remove stone from bile duct, Abx, interval lap chole

36
Q

what is gallstone ileus?

A

stone eroding through GB into the GI tract like the duodenum, ileum or colon

37
Q

what is a cholecystenteric fistula?

A

communication between the GI and gallbladder

  1. Bouveret syndrome = gallstone in duodenum
  2. gallstone ileus = stone in the ileum
38
Q

what is gallstone cancer?

A

caused by allstones in 80%

more common in emale gender

risk is greater with large stones and with American Indian

associates with Primary Sclerosing Cholangitis

associates with Anomalous pancreaticobiliary union

the risk is too low to recommend prophylactic cholecystectomy

treatment: Surgery
prognosis: 5 year survival is 0-10%.

39
Q

what are sphincter of odd dysfunction?

A

spasm or stenosis of sphincter

increased pressure after removing gallbladder can cause pain or spasms

can cause elevated liver enzymes

you can cut the sphincter to treat if it’s bad

40
Q

what are choledochol cysts?

A

congenital cysts of the bile ducts and they’re all pre-malignant except type 3!!!

most common eastern asia

presents with pain jaundice and/or palpable mass
surgical excision required to prevent cholangiocarcinoma

41
Q

which imaging do you do to look for gallstones in the gallbladder vs. bile duct?

A

gallbladder:
1. US

  1. HIDA scan

CBD

  1. MRCP
  2. EUS
  3. ERCP
  4. IOC

GI Week 4 (9 decks)

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