GI: Biliary Colic and Cholecystitis

Question 1

Why can gallstones form? What are the different types?

Answer 1

Form if the concentrations of bile constituents change (cholesterol, bile pigments and phospholipids).

1. CHOLESTEROL STONES (80%) - bile acids and excess cholesterol crystalise and precipitate.
2. BLACK PIGMENT STONES - excess bilirubin, e.g. haemolysis (e.g. sickle cell anaemia, hereditary spherocytosis, thalassaemia) or cirrhosis
3. MIXED STONES - composed of calcium salts, pigment and cholesterol
4. BROWN PIGMENT STONES (<5%) - form due to stasis and infection within biliary system (E. coli and Klebsiella spp.)

Question 2

suggest risk factors for gallstone formation

Answer 2

• ‘fair, fat, fertile, female and forty’
• increasing age
• +ve FHx
• sudden weight loss, e.g. after weight loss surgery
• diabetes, as part of metabolic syndrome
• oral contraception, esp. in younger women

Question 3

describe the most common presentation of symptomatic gallstones

Answer 3

BILIARY COLIC (temporary obstruction of cystic duct or common bile duct by stone):

• sudden onset epigastric or RUQ pain
• pain may radiate to right shoulder
• often precipitated by fatty meals
• persists from 15 mins up to 24 hrs, subsiding spontaneously or with analgesics
• +/- nausea and vomiting

Question 4

how would you investigate suspected gallstone disease?

Answer 4

USS biliary tract: best way to demonstrate GB stones or cholecystitis, and allows measurement of CBD diameter and visualisation of liver and hepatic bile ducts

Question 5

how would you manage a pt with biliary colic?

Answer 5

Many pts can be initially managed at home.

i) intermittent mild-moderate pain: oral paracetamol or oral/rectal diclofenac
ii) for rapid relief of severe pain: diclofenac 75mg IM (with 2nd dose 30mins later if necessary) or consider IM morphine or pethidine if diclofenac not suitable or ineffective
iii) refer to GI surgeons for elective laparoscopic cholecystectomy
iv) pain continuing for >24 hrs or accompanied by fever usually requires hospital admission

Question 6

what causes acute cholecystitis?

Answer 6

Gallstone impaction in cystic duct… bile stasis and increased pressure… GB distention… necrosis and ischaemia of mucosal wall.

+/- bacterial infection (usually E. coli)

Question 7

how would a pt with acute cholecystitis present?

Answer 7

• continuous epigastric or RUQ pain
• fever, systemically unwell
• nausea and vomiting
• local tenderness or peritonism
• GB mass
• +ve Murphy’s sign

Question 8

suggest risk factors for cholecystitis

Answer 8

• gallstones (95%)
• hospitalisation for trauma or acute biliary illness (5% without gallstones)
• female
• increased age
• rapid weight loss
• pregnancy
• Crohn’s disease
• hyperlipidaemia

Question 9

how would you diagnose a pt with suspected cholecystitis?

Answer 9

1. Bloods
   - FBC: raised WCC
   - LFTs: often mildly abnormal
2. USS biliary tract: allows visualisation of stones. Findings in cholecystitis include:
   • thickened GB wall (>3 mm)
   • +/- pericholecystic fluid
   • +/- air in GB or GB wall

Question 10

how would you manage a pt with acute cholecystitis?

Answer 10

i) urgent admission to hospital for:
- IV fluids
- IV antibiotics (e.g. ceftriaxone if mild, meropenem if severe)
- parenteral analgesia (morphine or pethidine +/- diclofenac suppository)

ii) open or laparoscopic cholecystectomy within 7 days of symptom onset

Question 11

suggest possible complications of gallstone disease

Answer 11

1. empyema: obstructed GB fills with pus - pt becomes toxic with marked fever and leukocytosis
2. gallstone ileus: causing bowel obstruction
3. cholangitis: obstruction of CBD and secondary infection
4. pancreatitis: obstruction of biliopancreatic duct
5. chronic cholecystitis: if repeated episodes of acute cholecystitis