Gallstones and Biliary Colic

Question 1

Define gall stones

Answer 1

Formation of stones (choleliths) in the gallbladder
Cholelithiasis – gallstones in the gallbladder
Choledocholithiasis – gallstones in the biliary tree

Question 2

Define biliary colic

Answer 2

temporary obstruction of the cystic or bile duct with a gallstone

Question 3

What are the causes/risk factors of gallstones?

Answer 3

Cholesterol gallstones (85-90%)
• Family history
• Increasing age
• Female (3:1)
• Obesity
• Drugs e.g. OCP, octreotide
• Pregnancy
• TPN, rapid weight loss (bile stasis)
• Terminal ileum disease (interrupted enterohepatic circulation)
• (Female, forty, fat, fertile, fair)

Pigment gallstones (<15%) – calcium bilirubinate
• Chronic haemolytic anaemia
• Cirrhosis
• Cystic fibrosis
• Ileal disease
• Bile duct strictures

Question 4

What are the symptoms of gall stones?

Answer 4

• Asymptomatic (90%)

Biliary colic
• RUQ or epigastric pain (sudden onset, constant, severe, may radiate to R shoulder, after a fatty meal, lasts for hours)
• Nausea & vomiting

Cholecystitis
• RUQ or epigastric pain (prolonged,
may radiate to R shoulder)
• Fever

Cholangitis
• Charcot’s triad
- RUQ pain
- Fever (rigors)
- Jaundice (dark urine, pale
stool, pruritus)
• Reynold’s pentad
- Hypotension/shock
- Confusion

Question 5

What are the signs of gallstones?

Answer 5

Biliary colic
• RUQ or epigastric tenderness

Cholecystitis
• RUQ or epigastric
tenderness/guarding
• Murphy’s sign
• Tachycardia
• Pyrexia

Cholangitis
• RUQ tenderness
• Jaundice
• Pyrexia

Question 6

What investigations are carried out for gallstones?

Answer 6

• FBC - normal in simple biliary colic
• serum LFTs - cholelithiasis: normal; choledocholithiasis: elevated alkaline phosphatase, elevated bilirubin
• serum lipase and amylase - elevated (>3 times upper limit of normal) in acute pancreatitis
• abdominal ultrasound- cholelithiasis: stones in the gallbladder; choledocholithiasis: stones in the bile duct with or without bile duct dilation

Question 7

What is the management of gallstones?

Answer 7

ACUTE
symptomatic cholelithiasis
• 1st line -
cholecystectomy

choledocholithiasis with or without symptoms
• 1st line - endoscopic retrograde cholangiopancreatography (ERCP)
• Adjunct - lithotripsy, papillary balloon dilation, or long-term biliary stenting
• 2nd line - laparoscopic common bile duct exploration

ONGOING
asymptomatic cholelithiasis
• 1st line - observation

Question 8

What are the complications of gallstones?

Answer 8

• Cholecystitis (inflammation of the gallbladder)
• Blockage of the common bile duct
• Blockage of the pancreatic duct
• Gallbladder cancer