Gallstones Flashcards
(30 cards)
Gallstone contents
- Phospholipids
- Bile pigments (broken down Hb) - associated with haemolysis - sickle cell anaemia
- Cholesterol
Risk factors for gallstones (5Fs)
- Female
- Fat
- Fertile - OCP, pregnancy
- Forty +
- FHx
- Loss of terminal ileum (↓ bile salts)
Complications of gallstones in the gall bladder
- Biliary Colic
- Acute cholecystitis ± empyema
- Chronic cholecytsitis
- Mucocele
- Carcinoma
- Mirizzi’s syndrome
- Fistula
Mirizzi’s syndrome
Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
Ix - MRCP
Mx- laparoscopic cholecystectomy.
Biliary colic
Gallbladder spasm against a stone impacted in the neck of the gallbladder – Hartmann’s Pouch
Presentation of gallstones
Biliary colic
- sudden dull RUQ pain radiating to back (scapular region)
- Associated with sweating, pallor, n/v
- Aggravated by fatty food and last <6h
- o/e may be tenderness in right hypochondrium
- ± jaundice if stones passes in to CBD
Acute cholecystitis sign
Murphy’s sign +ve
- when palpating RUQ, painful when inhaling
- -ve on left
Investigations for gallstones
- Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP
- Urine: bilirubin, urobilinogen, Hb
- Imaging
- AXR: 10% of gallstones are radio-opaque
- Erect CXR: perforation
- Transabdo USS (first line)
• If diagnosis uncertain after USS - HIDA cholescintigraphy: shows failure of GB filling
(requires functioning liver)
• If dilated ducts seen on USS → MRCP (gold standard)
Treatment of gallstones
• Conservative
- Low fat diet, exercise
- Monitor LFTs: passage of stone spontanously
- Give vitamins ADEK
- Analgesia - morphine
- Cholestyramine - bile acid sequestrant preventing reabsorption
- Rehydrate
Surgery:
If no resolution, worsening LFTs or cholangitis:
- ERCP with sphincterotomy and stone extraction
Offered within 6 weeks of first presentation:
- Laparoscopic cholecystectomy
Acute cholecystitis
- Stone impaction in Hartmann’s pouch or cystic duct
* chemical and/or bacterial inflammation
Sequelae of acute cholecystitis
- Resolution ± recurrence
- Gangrene and rarely perforation
- Chronic cholecystitis
- Empyema
Presentation of acute cholecystitis
• Severe RUQ pain - Continuous - Radiates to right scapula and epigastrium • Fever • Vomiting
Examination: • Local peritonism in RUQ • Tachycardia with shallow breathing • ± jaundice • Murphy’s sign
Investigations for acute cholecystitis
•Bloods
- FBC: ↑ WCC
- U+E: dehydration from vomiting
- Amylase, LFTs, G+S, clotting, CRP
- Urine - bilirubin, urobilinogen
- Imaging
- AXR: gallstone, porcelain gallbladder
- Erect CXR: perforation
- USS - 1st line
- If the diagnosis is uncertain after USS - HIDA cholescintigraphy which shows failure of GB filling (requires functioning liver)
- MRCP if dilated ducts seen on USS (gold standard)
Management of acute cholecystitis
Conservative:
- NBM
- Fluid resuscitation
- Analgesia: paracetamol, diclofenac, codeine
Medication:
- Abx: cefuroxime and metronidazole
Surgical
- Elective laparoscopic cholecystectomy surgery - within 1 week
- <72h ideal
- percutaneous cholecystostomy - if not fit for surgery and not responding to abx
Chronic Cholecystitis
Symptoms: Flatulent Dyspepsia • Vague upper abdominal discomfort • Distension, bloating • Nausea • Flatulence, burping • Symptoms exacerbated by fatty foods
Investigations for Chronic Cholecystitis
- AXR: porcelain gallbladder
- USS: stones, fibrotic, shrunken gallbladder
- MRCP
Mx of chronic cholecystitis
Mx
• Medical
- Bile salts (not very effective)
• Surgical
- Elective cholecystectomy
- ERCP first if US shows dilated ducts and stones
Mucocele
Neck of gallbladder blocked by stone but contents remains sterile
• Can be very large → palpable mass
• May become infected → empyema
Gallstone ileus
Stone impacts at the terminal ileum causing small bowel obstruction
Rigler’s Triad
Pneumobiliia
Small bowel obstruction
Gallstone in RLQ
Bouveret’s syndrome
Obstruction of proximal duodenum by a gall- stone in the gallbladder causing duodenal obstruction
Ascending Cholangitis
- Obstruction of common biliary duct with infection
- Charcot’s triad:
- fever/rigors
- RUQ pain
- jaundice
- Reynolds pentad: Charcot’s triad + shock + confusion
- Mx
- urgent drainage if sepsis
- abx - Cef and met
- 1st: ERCP
- 2nd: Open or lap stone removal
Pigment stones
Commonly seen in those with known haemolytic anaemia
USS findings
- Stones: acoustic shadow
- Dilated ducts (>6mm)
- Inflamed GB: wall oedema
