Gallstones

Question 1

Prevalence of gallstones?

Answer 1

• up to 24% and 12% of men may have gallstone
• of these up to 30% may develop local infection and cholecystitits
• in patients subjected to surgery, 12% will have stones contained within the common bile duct

Question 2

What do gallstones consist of?

Answer 2

the majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases.

Question 3

Classical symptoms of gallstones

Answer 3

• colicky right upper quadrant pain thta occurs postprandially
• the symptoms are usually worst following a fatty meal and cholecystokinin levels are highest and gallbladder contraction is maximal

Question 4

Investigation of gallstones?

Answer 4

• standard diagnostic workup consists of abdominal ultrasound and liver function tests
• of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFTs
• Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct the options lie between magnetic resonance cholangiography and intraoperative imaging.

Question 5

Biliary Colic features and management?

Answer 5

colicky abdominal pain, worse postprandially, worse after fatty foods

If imaging shows gallstones and history compatible then laparoscopic cholecystectomy

Question 6

Acute cholecystits features and management?

Answer 6

RUQ pain
Fever
Murphy’s sign on exam
mildy deranged LFT’s

Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation)

Question 7

Gallbladder abscess features and managment?

Answer 7

usually prodromal illness and right upper quadrant pain

swinging pyrexia

patient may be systemically unwell

generalised peritonism not present

Imaging with USS +/- CT scanning, ideally surgery although subtotal cholecystectomy may be needed if Calot’s triangle is hostile

in unfit patients, percutaneous drainage may be considered

Question 8

Cholangitis features and managment?

Answer 8

Patient severely septic and unwell

Jaundice

RUQ pain

Fluid resuscitation, broad-spec IV antibiotics, correct any coagulopathy, early ERCP

Question 9

Gallstone ileus features and management?

Answer 9

Patients have have a history of previous cholecystitis and known gallstones
small bowel obstruction (may be intermittent)

Laparotomy and removal of the gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction

The fistula between the gallbladder and duodenum should not be interfered with

Question 10

Acalculous cholecystits features and treatment?

Answer 10

Patients with intercurrent illness (e.g. diabetes, organ failure)

Patient of systemically unwell Gallbladder inflammation in absence of stones

High fever

If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy

Question 11

Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may, therefore, be managed:

Answer 11

Expectantly (observation)

In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient, there is sometimes a role for the selective use of ultrasound guided cholecystostomy.

Question 12

Risks of ERCP

Answer 12

• Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
• Duodenal perforation 0.4%
• Cholangitis 1.1%
• Pancreatitis 1.5%

Question 13

Risks of ERCP

Answer 13

• Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
• Duodenal perforation 0.4%
• Cholangitis 1.1%
• Pancreatitis 1.5%