Gallstones (inc. bile duct stones)

Question 1

What is the definition of gallstones/bile duct stones?

Answer 1

Hard crystallized mass formed abnormally in the gall bladder/bile ducts

Question 2

How common are gallstones?

Answer 2

10-15% of adults in the Western world

Question 3

What is the pathology of gallstones/bile stones?

Answer 3

• 2 type of gallstone: cholesterol and pigment/bilirubin stones (Ca, Cu)
• High fat foods cause the secretion of bile into the intestine = emulsification
• Supersaturation of cholesterol means the bile salts can no longer keep cholesterol dissolved = precipitate out
• Not enough salts/acids = precipitation
• Gallbladder stasis = precipitation (like oil in a PB jar)
• Too much bilirubin that combines with Ca = precipitate

Question 4

What are the risk factors/aetiology of gallstones/bile stones?

Answer 4

• Age (less common in under 30’s)
• Gender – 2/3 times more common in woman
• Race – more common in Scandinavians, south Americans and native north Americans
• Obesity
• Metabolic syndromes
• Rapid weight loss
• Diabetes
• High cholesterol diet
• High oestrogen levels – pill, pregnant, HRT
• Cirrhosis, primary sclerosing cholangitis, Crohn’s disease, IBS
• Cefriaxone
• Acromegaly treated with octreotide

Question 5

What are the signs/symptoms of gallstones/bile stones?

Answer 5

• Majority asymptomatic
• Sudden constant dull epigastric/right hypercondrium pain – may radiate to right flank/scapula, can be triggered by fatty foods
• Murphy’s sign – pain at right subcostal margin due to gallbladder/liver inflammation
• Nausea/vomiting
• Indigestion
• Bloating/burping
• Pain = biliary colic
• Pain + temp = cholecystitis
• Pain + temp + jaundice = cholangitis

Question 6

What are diseases that present similarly to gallstones/bile stones?

Answer 6

• IBS
• Renal colic
• Carcinoma of the R side of the colon
• Atypical peptic ulcer disease
• Pancreatitis
• Intrahepatic abscess
• MI - rare
• Basal pneumonia - rare

Question 7

What investigations are carried out for suspected gallstones/bile stones?

Answer 7

• Bloods – FBC (leucocytes slightly ↑), LFT’s, amylase/lipase (pancreatic complications)
• Serum bilirubin ↑
• Alkaline phosphatase ↑
• Aminotransferase ↑
• Abdominal US
• MRI – gallstones in the bile ducts
• Cholangiography – contrast xray to find a blockage
• Biliary scintigraphy – to find duct obstruction
• CT – if any complications e.g. acute pancreatitis

Question 8

What are the surgical treatments for gallstones/bile stones?

Answer 8

• Laproscopic cholecystectomy
• Open cholecystectomy – 3rd trimester of pregnancy, extremely overweight, unusual anatomy that makes keyhole difficult
• Endoscopic retrograde cholangio-pancreatography (ERCP)
• Stone dissolution and shock wave lithotripsy

Question 9

What are the pharmacological treatments for gallstones/bile stones?

Answer 9

• Statins
• Analgesia
• Ursodeoxycholic acid – dissolves gallstones
• IV antibiotics
• Fluids

Question 10

What are the non pharmacological treatments for gallstones/bile stones?

Answer 10

• Low cholesterol diet
• Avoiding trigger foods e.g. fatty, spicy foods
• NBM