Gallstones including bile duct stones

Question 1

How common is it?

Answer 1

In developed countries, gallstones occur in 7% of males and 15% of females aged 18–65 years, with an overall prevalence of 11%.

Question 2

Who does it affect?

Answer 2

In individuals under 40 years there is a 3 : 1 female preponderance, whereas in the elderly the sex ratio is about equal. In developed countries, the incidence of symptomatic gallstones appears to be increasing and they occur at an earlier age.

Question 3

What causes it?

Answer 3

Gallstones are classified into cholesterol or pigment stones, although the majority are of mixed composition.
Cholesterol stones are most common in developed countries, whereas pigment stones are more frequent in developing countries.

Cholesterol:

• Defective bile salt synthesis
• Excessive intestinal loss of bile salts
• Over-sensitive bile salt feedback
• Excessive cholesterol secretion
• Abnormal gallbladder function

Pigment:
- almost always the consequence of bacterial or parasitic biliary infection.

Question 4

What risk factors are there (and how can they be reduced)?

Answer 4

Cholesterol stones:

• increased secretion (old age, female, pregnancy, obesity, rapid weight loss)
• impaired gall bladder emptying (pregnancy, gallbladder stasis, fasting, total parenteral nutrition, spinal cord injury)
• decreased bile salt secretion (pregnancy)

Black pigment stones:

• haemolysis
• age
• hepatic cirrhosis
• ileal resection/disease

Brown pigment stones:

• infected bile
• stasis

Question 5

How does it present? What symptoms should you look out for?

Answer 5

Only 10% of people with gallstones develop clinical disease.

• Epigastric (70%) or RUQ (20%) pain, may radiate to interscapular region or scapular tip (Collin’s sign), may last from 1 to few hours
• Pain is often postprandial (around an hour after a fatty meal)
• Constant in nature, not relieved by vomiting/antacids etc
• Other sites of pain include LUQ and lower chest
• Nausea, sweating, vomiting
• Indigestion, dyspepsia, belching, fat intolerance

Question 6

What signs may the patient have on examination?

Answer 6

May have no abnormal findings on physical examination.

Since gallbladder is not inflamed in uncomplicated biliary colic the patient has an essentially benign abdominal examination without rebound or guarding.

In acute cholecystitis, inflammation of the gallbladder with resultant peritoneal irritation leads to a well-localized pain in the right upper quadrant, usually with rebound and guarding.

A positive Murphy sign (inspiratory arrest on deep palpation of the right upper quadrant during deep inspiration) is highly suggestive of cholecystitis.

Although voluntary guarding may be present, no peritoneal signs are present.

The presence of fever, persistent tachycardia, hypotension, or jaundice necessitate a search for complications

Choledocholithiasis with obstruction of the common bile duct produces cutaneous and scleral icterus that evolves over hours to days as bilirubin accumulates.

Question 7

Which other conditions might present similarly?

Answer 7

Acute Pancreatitis
Appendicitis
Bile Duct Strictures
Bile Duct Tumours
Cholangiocarcinoma
Cholecystitis
Emergent Treatment of Gastroenteritis
Gallbladder Cancer
Pancreatic Cancer
Peptic Ulcer Disease

Question 8

How would you investigate this patient?

Answer 8

• USS, transabdominal or endoscopic (ERCP)
• MRCP

If complications suspected:
- FBC, LFT lipase and amylase

Question 9

What would you tell the patient and how would you explain the condition to them?

Answer 9

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. In most cases they don’t cause any symptoms and don’t need to be treated.

However, if a gallstone becomes trapped in an opening (duct) inside the gallbladder, it can trigger a sudden, intense abdominal pain that usually lasts between one and five hours. This type of abdominal pain is known as biliary colic.

Some people with gallstones can also develop complications, such as inflammation of the gallbladder (cholecystitis).

Question 10

How do you think the patient and/or family might be affected by the diagnosis? Will it affect their
ability to work/care for themselves?

Answer 10

If treated promptly, simple gallstones should not have a huge impact.

If the patient develops complications they may have more or a serious impact.

Question 11

What questions are they likely to have?

Answer 11

Do I need surgery?
Will this happen again?
Is there anything I can to to make sure it doesn’t happen again.

Question 12

What treatment/s (surgical, pharmacological and non-pharmacological) would you discuss with
them? What risks and benefits of treatment are there?

Answer 12

Gallbladder stones:

• Cholecystectomy: open or laparoscopic
• Oral bile acids: chenodeoxycholic or ursodeoxycholic (low rate of stone dissolution)

Bile duct stones:

• Lithotripsy (endoscopic or extracorporeal shock wave, ESWL)
• Endoscopic sphincterotomy and balloon trawl
• Surgical bile duct exploration

Question 13

What is the general composition of pigment stones?

Answer 13

Black:

• Polymerised calcium bilirubinates
• Mucin glycoprotein
• Calcium phosphate
• Calcium carbonate
• Cholesterol

Brown:

• Calcium bilirubinate crystals
• Mucin glycoprotein
• Cholesterol
• Calcium palminate/stearate