Gallstones and biliary colic

What are gallstones?

small stones that form within the gallbladder, can take years to form

What are consequences of gallstones?

they can be asymptomatic , or they can present with acute disease

about 60% of these presentations are biliary colic, and the rest are acute cholecystitis, acute cholangitis, and pancreatitis

What is the anatomy of the biliary system?

the right and left hepatic ducts leave the liver and join to form the common hepatic duct. The cystic duct leaves the gallbladder, and joins the common hepatic duct, to become the common bile duct. The pancreatic duct joins the common bile duct to become the ampulla of vater, which opens to the duodenum through the sphincter of oddi.

What is cholestasis?

blockage to the flow of bile

What is cholelithiasis?

gallstones

What is choledocholithiasis?

gallstones in the bileduct

What is biliary colic?

intermittent right upper quadrant pain caused by gallstones irritating bile ducts

What is cholecystitis?

inflammation of the gallbladder

What is cholangitis?

inflammation of the bile ducts

What is gallbladder empyema?

pus in the gallbladder

What is cholecytsectomy?

surgical removal of the gallbladder

What is cholecystostomy?

inserting a drain into the gallbladder

What are types of gallbladder stones?

cholesterol stones- usually solitary and large made of cholesterol and calcium

pigment stones- black hard stones

mixed- multiple and irregular shaped

What is the epidemiology of gallstones?

more common in women

incidence increases with age

• At age 30 – 5% of women and 2% of men have / have had gallstones. Aged 55 – 20% / 10%, age 70, 30% / 20%.

What are risk factors for gallstones?

fat

female

forty

fair

family history

fertile

diabetes, crohn’s, rapid weight loss

How are cholesterol stones formed?

cholesterol stones form when the concentration of micelles is not great enough to hold all the cholesterol in the micelles. For cholesterol stones to form there need to be three factors:

• High concentration of cholesterol in the gallbladder

• Gallbladder stasis

• Products that promote the crystallisation of cholesterol

initially, cholesterols will form crystals which go on to form stones

What inhibits stone formation?

caffeine

NSAIDs

bile salts

What exacerbates stone formation?

mucin, rapid weight loss, pregnancy, increased serum cholesterol, oral contraceptive, clofibrate

How are pigment stones formed?

1. increase in bilirubin load as a result of haemolytic anaemia

2. cirrhosis

3. pigments become less water soluble in the bile if the gallbladder is colonised by bacteria

What are symptoms of biliary colic?

severe, colicky, epigastric/RUQ pain, that can radiate to shoulder/interscapular region

often triggered by meals (high fat)

last between 3-8 hours

nausea and vomiting

no fever/raised inflammatory markers

Why can fatty foods trigger biliary colic?

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic. Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction

What are differential diagnosis for biliary colic?

GORD

peptic ulcer

IBS

pancreatitis

What investigations are done for biliary colic?

LFTs

ultrasound- gold standard diagnostic test

What could LFTs show in biliary colic?

bilirubin- normally drains through the bile ducts, raised bilirubin (with pale stools and dark urine) show biliary obstruction

ALP- non-specific marker made in the liver, biliary system, and bone. Raise in this with consistent symptoms could show biliary obstruction

ALT/AST- normally indicative of hepatocellular injury, but a slight raise, less than ALP, could show an obstructive picture

What is the first line investigation for gallstone disease?

US

What findings can be found on US for biliary colic?

• gallstones in gallbladder or duct

• bile duct dilation

• acute cholecystitis (thickened gallbladder wall, fluid around gallbladder)

What is MRCP?

magnetic resonance cholangio-pancreatography

MRI scan that produces detailed biliary images. Normally used to investigate further if found bile duct dilation but no gallstones on US

What is endoscopic retrograde cholangio-pancreatogrophy?

ERCP

involves inserting endoscope down the oesophagus to the opening of the common bile duct in the duodenum.

the main indications is to clear stones in the bile duct

What can ERCP do?

• Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures)

• Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow)

• Clear stones from the ducts

• Insert stents to improve bile duct drainage (e.g., with strictures or tumours)

• Take biopsies of tumours

What are complications of ERCP?

bleeding

cholangitis

pancreatitis

What is management of gallstones?

is asymptomatic- conservative treatment

symptoms or complications- elective laparoscopic cholecystectomy

What is courvoisier’s sign?

palpable gallbladder- this is usually a sign of acute pathology, eg: malignancy/obstruction of the pancreas

gallstones result in shrunken, fibrotic gallbladder

What is cholecystectomy?

involves surgical removal of the gallbladder. It is indicated where patients are symptomatic of gallstones, or the gallstones are leading to complications

can be open or laparoscopic (preferred)

What are complications of cholecystectomy?

• bleeding, infection- normally given prophylaxis >40

• scars

• damage to bile duct

• stones left in duct

• damage to other organs

• anaesthetic risk

• VTE- given prophylaxis

• post-cholecystectomy syndrome

What is post-cholecystectomy syndrome?

non-specific symptoms attributed to changes in bile flow:

• diarrhoea

• indigestion

• epigastric/RUQ discomfort

• nausea

• flatulence

• intolerance of fatty foods