General: Gallstones - Billiary Colic and Cholecystitis

Question 1

Outline the pathophysiology of gallstones

Answer 1

Bile = cholesterol, phospholipids, and bile pigments, stored in the gallbladder

Gallstones = supersaturation of the bile

1. Cholesterol stones = excess cholesterol production (poor diet, obesity)
2. Pigment stones = excess bile pigments production (haemolytic anaemia)
3. Mixed stones = both cholesterol and bile pigments

Question 2

What are the risk factors for gallstones

Answer 2

Risk factors (5 F’s)

• Fat
• Female
• Fertile
• Forty
• Family history

Question 3

What is murphy’s sign?

Answer 3

Apply pressure in RUQ

Inspire

+ve = halt in inspiration due to pain indicating inflamed gallbladder

Question 4

How do gallstones present?

Answer 4

Asymptomatic

Biliary colic (contraction of the gallbladder against the occluded neck) = sudden, dull, colicky, RUQ pain, precipitated by fatty foods

Acute cholecystitis (blockage of cystic duct by gallstone causing inflam of the gallbladder) = constant pain, fever, tender RUQ, +ve Murphy’s sign

Empyema = v systemically unwell pt

Perforation and necrosis = generalised peritonitis

Question 5

What investigations can be performed for suspected gallstones?

Answer 5

Urinalysis (?pregnancy) = exclude any renal and tubo-ovarian pathology

FBC, CRP = raised in cholecystitis, cholangitis, and pancreatitis

U+Es = dehydration, secondary to reduced oral fluid intake (certain foods can worsen the pain)

LFTs = biliary colic and acute cholecystitis are likely to show a raised ALP (indicating ductal occlusion)

Amylase = ?pancreatitis

Trans-abdo US = presence of gallstones, gallbladder wall thickness, bile duct dilation

Magnetic Resonance Cholangiopancreatography (MRCP) = show defect in biliary tree

Question 6

Outline the best management for gallstones

Answer 6

Analgesia = NSAIDs, PRN opioids

Antiemetic

Lifestyle changes = low fat diet, weight loss, increasing exercise

Laparoscopic cholecystectomy

ERCP = remove stone

Cholecystitis = IV Abx, fluid resuscitation, oxygen, NG tube, NBM, laparoscopic cholecystectomy

Question 7

What are the possible complications of gallstones?

Answer 7

Gallbladder empyema

Chronic cholecystitis

Bouveret’s Syndrome = stone impacts to cause duodenal obstruction

Gallstone Ileus = stone impacts to cause an obstruction at the terminal ileum

Mirizzi syndrome = gallstone becomes impacted in the cystic duct or neck of the gallbladder

Question 8

What is cholecystitis and how should it be Ix?

Answer 8

Inflammation in the gallbladder - usually caused by gallstones

Acute = associated with secondary infection (bile normally sterile - sphincter of Oddi)

Ix = USS, CT (fistula, abscess, necrosis)

Question 9

What is biliary colic?

Answer 9

Gallstone gets stuck in the neck of the gallbladder (Hartman’s pouch) in the cystic duct

The contraction of the muscular gallbladder against a blockage = pain

Question 10

What are the indications for surgery in gallstones?

Answer 10

Recurrent biliary colic

Acute cholecystitis = laparoscopic cholecystectomy

Gallbladder empyema

Chronic cholecystitis

Question 11

What is cholangitis?

Answer 11

Inflammation of the bile duct