Week 7/8 - B - Gallstone - risk factors/type, (Biliary colic, acute/chronic cholecystitis, choledocholithiasis, cholangitis, G.B cancer)

Question 1

What is the medical term for gallstone? What is a gallstone?

Answer 1

Gallstones medically are known as cholelithiasis Gallstones are defined as hard stone-like or gravel-like material formed within the biliary system most commonly in the gallbladder

Question 2

Where is normal bile produced and what does it contain? Where is it stored and concentrated and how is passed into the small intestine?

Answer 2

Normal bile is produced in the liver -> Micelles of Cholesterol (hydrophobic), Bile pigments (bilirubin from broken down Hb in the spleen) Bile salts (hydrophilic) And phospholipids They are stored and concentrated in the GB and released in response to CCK (from I cells of duodenum) into the 2nd part of duodenum through the major duodenal papilla

Question 3

What are the typical 5Fs risk factors for gallstones? - * how do they increase risk for gallstone formation

Answer 3

Risk factors - it is traditional to refer to the ‘5 F’s’: Female: gallstones are 2-3 times more common in women. Oestrogen increases activity of HMG-CoA reductase Fat: obesity is thought to be a risk factor due to enhanced cholesterol synthesis and secretion (BMI>30kg/m2 and hyperlipidaemia) Forty Fertile: pregnancy is a risk factor Fair

Question 4

Apart from the female, fat, forty, fertile and fair risk factors for gallstones, what are other known risk factors?

Answer 4

* Bile salt loss - eg due to crohn’s * Diabetes mellitus * Rapid weight loss * Combined oral contraceptive pill

Question 5

Why do we get gallstones? (brief pathogenesis summary)

Answer 5

We get gallstones when there is abnormal bile composition due to an imbalance between the ratio of cholesterol to bilirubin to bile salts disrupting micelle formation

Question 6

There are different categories of gallstones What are these categories? - which is most common

Answer 6

Mixed gallstone - most common Cholesterol gallstones Pigmented gallstones Primary bile duct stones (very rare)

Question 7

What colour are mixed gallstones typically? What are the common constituents of this stone type?

Answer 7

Mixed gallstones are brownish in colour Common constituents include * calcium salts (hence may be visible on xray) * pigment - bilirubin * cholesterol

Question 8

What is the cause of cholesterol gallstones formation? How do they appear? What are the risk factors?

Answer 8

Cholesterol gallstones form when there is increased cholesterol - the stones are usually yellow in colour and often large and solitary Risk factors include age, obesity, female (oestrogen increase HMG CoA reducatase)

Question 9

What is the cause of bilirubin (pigment) gallstone formation? How do they appear?

Answer 9

Pathogenesis is due to excess bilirubin formation due to excess haemolysis (eg haemolytic anaemias) Cause the formation of usually numerous, black stones which are usually small and friable

Question 10

What are the different complications of gallstone formation? - ie what conditions can it cause

Answer 10

* Biliary colic * Acute cholecystitis * Chronic cholecystitis * Ascending cholangitis * Acute pancreatitis * Chronic pancreatitis * Gallstone ileus * Gallbladder carcinoma * Gallbladder mucocel/empyema

Question 11

Biliary Colic What are the presenting features of biliary colic? When is the feature worse and how long does it last?

Answer 11

In biliary colic, there is a gallstone lodged within the cystic duct * Patients presents with colicky pain in the RUQ that can radiate to the back or shoulders * The pain is usually worse post-prandially on eating fatty foods and may last 2-6 hours It is associated with indigestion/nausea (maybe vomiting) and usually there is not jaundice

Question 12

How is biliary colic diagnosed? What is seen on LFTs?

Answer 12

Biliary colic is typically diagnosed on ultrasound scan of the patients RUQ LFTs are usually normal unless the gallstone is blocking the common bie duct (choledocholithiasis) - causes obstructive jaundice picture

Question 13

If ultrasound fails to make the diagnosis of gallstones however it is still suspected, what can be carried out?

Answer 13

Magnetic resonance cholangiopancreatography (MRCP)/ERCP, if ultrasound has not detected cystic duct stones but bile duct is dilated and/or LFTs are abnormal CT not usually recommended as the majority of stones are not radio-opaque

Question 14

What is recommended for the treatment of asymptomatic gallstones? * Found in gallbladder * Found in common bile duct

Answer 14

For a person with asymptomatic gallstones found in a normal gallbladder and normal biliary tree: Reassure them that they do not need treatment unless they develop symptoms. Explain that asymptomatic gallstones are very common. Prophylactic treatments aimed at preventing future complications are not recommended For a person with asymptomatic gallstones found in the common bile duct. * Offer referral for bile duct clearance and laparoscopic cholecystectomy — although they are asymptomatic, there is a significant risk of developing serious complications such as cholangitis or pancreatitis.

Question 15

What is the initial management of biliary colic?

Answer 15

Refer all people diagnosed with symptomatic gallstone disease to a surgeon to consider laparoscopic cholecystectomy (within 6 weeks) * Can give painkillers - typically NSAIDs for pain relief whilst awaiting surgery If the patient is unfit for surgery - ursodeoxycholic acid (secondary bile acid) is usually recommended

Question 16

Acute cholecystitis What happens in acute choleystitis? What is the presentation?

Answer 16

Acute cholecystitis is inflammation of the gallbladder that occurs due to obstruction of the cystic duct (usually due to gallstones)- initially sterile and then beomces infection Patient presents with * RUQ (can be epiigastric) pain that radiates to the right shoulder * Vomiting * Local peritonism or a gallbladder mass

Question 17

What is the main difference of acute cholecystitis from biliary colic?

Answer 17

Main difference is the inflammatory component - local peritonism, fever, increased WCC

Question 18

What is the sign that may be seen on exaimination in a patient with acute cholecystitis?

Answer 18

Murphy’s sign - 2 fingers are put over the RUQ and the patient is asked to breathe in - this causes pain and the arrest of inspiration as the inflamed GB impinges on the fingers

Question 19

How is acute cholecystitis diagnosed?

Answer 19

Diagnosis is the same as biliary colic US confirms diagnosis

Question 20

What is the treatment of acute cholecystitis?

Answer 20

Treatment * IV antibiotics and IV fluids * NBM Urgent laporascopic choleystectomy is then carried out - within 1 week of presentation (ideally within 48 hours)

Question 21

Acute cholecystitis can aries with complications such as empyema, rupture or peritonitis What is gallbladder mucocele/empyema? If the patient has had a gallbladder rupture, what may be carried out?

Answer 21

Gallbladder mucocele/empyema is when the obstructed GB fills with mucus/pus secreted by GB wall If the patient has had a gallbladder rupture, open cholecystectomy is usually recommended

Question 22

Chronic cholecystitis What happens in chronic cholecystitis? What is the usual causative factor?

Answer 22

In chronic cholecystitis there is usually repeated episodes of acute cholecystitis and is almost always due to gallstones It is characterized by repeated attacks of pain (biliary colic) that occur when gallstones periodically block the cystic duct.

Question 23

What happens to the gallbladder wall in chronic cholecystitis? What is the presentation of chronic cholecystitis?

Answer 23

In chronic cholecystitis, the gallbladder is damaged by repeated attacks of acute inflammation, usually due to gallstones, and may become thick-walled / scarred - not distended Presentation - Recurrent attacks of abdo pain/discomfort Can’t eat fatty foods Flatulent dyspepsia

Question 24

How is chronic cholecystitis treated?

Answer 24

Patient usually recieves a laproscopic cholecystectomy after the current attack subsides

Question 25

Complications of gallstones can occur should they migrate into the common bile duct (and potentially further) What is it known as when there is a gallstone in the common bile duct? What are some of these complications?

Answer 25

Choledocholithiasis (also called bile duct stones or gallstones in the bile duct) is the presence of a gallstone in the common bile duct Complications of migrating gallstones include \* Ascending cholangitis \* Pancreatitis - acute/chronic \* Gallstone ileus

Question 26

Choledocholithiasis What is the presentation of a patient with choledocholithiasis?

Answer 26

Patient with choledocholithiasis presents with RUQ constant pain \* The pain does not radiate and there is no asociated temperature As choledocholithiasis is due to a gallstone in the common bile duct, this blocks the flow of bile causing an obstructive jaundice

Question 27

What is seen on LFTs in choledocholithiasis? What imaging is used to diagnose it?

Answer 27

LFTs - shows an obstructive jaundice Raised bilirubin Raised ALP and GGT Ultrasound is the initial imaging of choice \* Diagnosis confirmed usually by MRCP \* If suspicion of CBD stones is high, ERCP may be used to diagnose and treat

Question 28

How is choledocholithiasis treated?

Answer 28

Bile duct clearance (using ERCP) and laparoscopic cholecystectomy to people with symptomatic or asymptomatic common bile duct stones (choledocholithiasis)

Question 29

Ascending cholangitis What is ascending cholangitis and how does a patient normally present?

Answer 29

Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones which is in the common bile duct and then the bile duct becomes infected Classic presentation is Charcot's triad - RUQ (constant) pain, fever and jaundice Also may have rigors

Question 30

Charcot's triad in acute cholangitis presentation include constant RUQ pain, fever and jaundice Which additional two symptoms can be added to this to form Reynold's pentad?

Answer 30

Reynolds pentad is a collection of signs and symptoms suggesting the diagnosis obstructive ascending cholangitis, It is a combination of Charcot's triad (RUQ pain, jaundice, and fever) with shock (low BP, tachycardia) and an altered mental status \* RUQ pain \* Fever \* Jaundice \* Low blood pressure \* Confusion

Question 31

How is ascending cholangitits diagnosed?

Answer 31

LFTs show rasied bilirubin, ALP and GGT Ultrasound is the initial first investigation carried out MRCP is usually te gold standard for common bile duct pathology diagnosis

Question 32

What is the treatment of ascending cholangitis?

Answer 32

Treatment of ascending cholangitis intravenous antibiotics endoscopic retrograde cholangiopancreatography (ERCP) to relieve any obstruction in the CBD

Question 33

Carcinoma of the gallbladder Pancreatitis (acute/chronic) and gallstone ileus will be discussed in another set of cards What type of cancer is this? What is it associated with?

Answer 33

Gallbladder cancer is an adenocarcinoma It has an associated with gallstones and primary sclerosing cholangitis

Question 34

What are the symptoms of gallbladder cancer? Why is prognosis poor?

Answer 34

Most often it is found after symptoms such as abdominal pain, jaundice and vomiting occur, and it has spread to other organs such as the liver. Other symptoms include weight loss, anorexia and pruritus Prognosis is poor due to late presentation and local invasion to eg liver

Question 35

What is the investigations to diagnose gallbladder cancer?

Answer 35

US is the initial imaging assessment CT scanning is the most useful imaging modality for both the diagnosis and staging of GBC. It is regarded as the best first-line investigation for suspected GBC as it can detect masses, as well as identify lymphadenopathy and tumour invasion into adjacent structures. MRCP good for assessing biliary tract involvement

Question 36

What is the treatment of gallbladder carcinoma?

Answer 36

The only curative therapy for GBC is surgical resection. Resection is contraindicated if the patient also has: Metastatic disease: the liver, peritoneum, and intestines are most commonly affected, but this includes distant metastasis. Malignant ascites Vascular invasion: