Cholelithiasis

Question 1

Outline the pathogenesis of cholelithiasis

Answer 1

• Cholesterol supersaturation or gallbladder hypomotility
  
  • 90% - cholesterol stones
  • 10% pigment stones
• Transient obstruction of the cystic duct - symptomatic cholelithasis (peristaltic biliary pain)

Question 2

What are some of the complications of cholelithiasis?

Answer 2

• Obstruction of the cystic duct - biliary pain/cholecystitis
• Obstruction of the common bile duct - biliary pain/cholangitis/obstructive jaundice
• Obstruction of the common pancreatic duct - acute gallstone pancreatitis

Question 3

What are the risk factors for the development of gallstones?

Answer 3

• Increasing age
• Female sex
• FHx
• Pregnancy, exogenous oestrogens, obesity
• Rapid weight loss
• Drugs (TPN, octreotide, ceftriaxone, clofibrate)
• Terminal ileum resection (loss of bile salts - cholesterol oversaturation)
• Diabetes/metabolic syndrome

Question 4

What signs and symptoms are likely to be present in a person with symptomatic cholelithiasis?

Answer 4

• RUQ/epigastric pain
  
  • Constant increasing >30min
• Postprandial pain
• Nausea
• RUQ/epigastric tenderness
• Jaundice (if choledocholithasis)

Question 5

What could be the investigative trail in someone suspected of having gallstones?

Answer 5

• LFTs - exclude choledocholithiasis
• Lipase/amylase - exclude pancreatitis
• US abdo
• ERCP

Question 6

How could you manage someone with cholelithiasis?

Answer 6

• Observation - if asymptomatic
• ERCP - if choledocholithiasis
• Cholecystectomy - if symptomatic cholelithiasis (e.g. multiple transient obstructions of cystic outlet)