Cholelithiasis

Question 1

Definition

Answer 1

Presence of stones in gallbladder.

Usually asymptomatic, problems when stick in biliary tree.

Question 2

Aetiology

Answer 2

Gallbladder concentrates bile, can=precipitation of stones.
-Pigment stones 10%- small, friable, irregular, black, multiple.
-Cholesterol stones 10%- large often solitary. Due to age and obesity.
-Mixed 80%- (Ca salt, pigment, cholesterol).
RFs- female, age, obesity, multiparity, diet, LDCs, OCP, ileal disease or resection (loss bile salts), haemolytic disease, rapid weight loss,
Hyperlipidaemia.
Can block bile flow and even pancreatic duct.

Question 3

Differentials

Answer 3

Peptic ulcer disease
GORD
IBS
Pancreatitis
Neoplasms- stomach, pancreas, colon, GB
Nonnuclear dyspepsia
Inferior MI
Hepatic abcess

Question 4

Management

Answer 4

Lifestyle- low fat but slow weight loss.
Analgesia, rehydration, NBM, IV AB if cholecystitis or cholangitis.
Asymptomatic no tx
Laparoscopic cholecystectomy
Oral bile salts for small cholesterol stones.
Extracorporeal shock wave lithotripsy.

Question 5

Symptoms and signs

Answer 5

• Biliary colic in cystic duct obstruction or if passed into CBD- RUQ pain radiates to back, possibly with jaundice. Pain 15mins to 24 hours, usually worse after food as CCK triggers gallbladder contraction.
• Acute cholecystitis due to stone impaction on gallbladder neck- contin epigastric or RUQ pain, vomit, fever, peritonism, GB mass, sepsis.
  Murphy sign- 2 fingers over RUQ, pain on inspiration.
• chronic cholecystitis- chronic inflammation possibly with colic. Flatulent dyspepsia, vague abdo discomfort, distension, nausea, fat intolerance (steatorrhoea)
• cholangitis- BD infection. RUQ pain, jaundice, rigors.
• gallstone ileus- stone through to duodenum.

Question 6

Complications

Answer 6

• gallbladder and cystic duct- biliary colic, acute and chronic cholecystitis due to stasis, mucocoele, empyema, carcinoma, perforation.
• In BD- obstructive jaundice, ascending cholangitis, pancreatitis, liver abcess, sepsis.
• gut- gallstone ileus.

Ascending cholangitis- RUQ pain, fever, jaundice.

Question 7

Symptoms

Answer 7

Biliary colic RUQ/epigastric/back.
Nausea and vomiting
Steatorrhoea
Pain upt o 24 hours and worse fater food.

Question 8

Signs

Answer 8

Fever
Jaundice
Peritonism
GB mass
Murpheys
Sepsis
Distension
Ascending cholangitis- RUQ pain, jaundice, rigours

Question 9

Diagnosis

Answer 9

urinalysis
CXR
ECG
LFT
US
ERCP uses endoscope and x rays
-biliary colic- RUQ pain intermittently, no fever, normal WCC, no jaundice.
-acute cholecystitis- continuous RUQ pain, fever, high WCC, no jaundice.
-cholangitis- RUQ pain, fever, high WCC, jaundice.

Question 10

Explanation

Answer 10

• The gallbladder is involved in concentrating a substance called bile. This helps with digestion and getting rid of waste. As it concentrates the bile, stones can form from the minerals it contains. Like the opposite of dissolving sugar.
• these stones often dont cause any trouble in the gallbladder. But if the move out of it they can block the ducts to the intestines which causes pain, infection, and digestion problems.
• lifestyle is important as the stones can form from cholesterol. So weight loss and a healthy diet are important to stop it happening again.
• at the time we will treat pain and infection and keep you hydrated. Then either wait to pass the stone or break up the stone, or remove the gallbladder.