Cholelithiasis

Question 1

What is the definition of cholelithiasis?

Answer 1

-the formation of gallstones in the gallbladder

Question 2

What age does it usually occur?

Answer 2

-40 years

Question 3

Why is it more prevalent in females than males?

Answer 3

-increased incidence of oestrogen

Question 4

What are the 3 types of gallstones?

Answer 4

1. cholesterol stones
2. black stones
3. brown stones

Question 5

What is the pathophysiology of the formation of gallstones?

Answer 5

• hypersaturation of cholesterol,calcium carbonate, bile salts and bilirubin
• biliary stasis
• decreased gallbladder emptying(pregnancy, bowel obstruction or prolonged parenteral feeding) which leads to cholestasis

Question 6

What are the 6 F’s?

Answer 6

1. fat
2. female
3. famiy history
4. fair skinned
5. forty
6. fertile

Question 7

What are the risk factors for cholesterol stone formation?

Answer 7

1. family history
2. obese
3. female
4. above 40
5. drugs-fibrates, oral contraceptives
6. pregnancy
7. malabsorption(crohns disease, ileal resection)

Question 8

What is the pathophysiology of cholesterol stone formation?

Answer 8

• increased concentration of cholesterol in the bile
• decreased bile salts and lecithin which leads to the bile being hypersaturated
• the cholesterol and he calcium carbonate precipitates out and forms cholesterol stones or mixed stones

Question 9

How do the black stones form?

Answer 9

• They occur 10% of the time
• caused by increased haemolysis which leads to increased unconjugated bilirubin and conjugated bilirubin uptake and the formation of black stones
• they are soft and crumble easily

Question 10

How do the brown/mixed stones form?

Answer 10

-They occur 10% of the time

Question 11

What are the risk factors for black stones?

Answer 11

• chronic haemolytic anaemias(sickle cell disease, hereditary spherocytosis)
• cirrhosis

Question 12

What are the clinical features of patients with gallstones?

Answer 12

• usually asymptomatic
• if they have pain: biliary colic dull RUQ pain that lasts <6 hours
• if it is referred then it goes to the epigastrium, right shoulder and the back
• usually post-prandially (right after eating)

Question 13

What are the diagnostic tests we can do for cholilithiasis?

Answer 13

• RUQ ultrasound is the best
• MRCP(magnetic resonance cholangiopancreatography) or EUS(endoscopic ultrasound)
• labs will be normal if uncomplicated(WBC, amlase and bilirubin)

Question 14

Why do we not use X-ray?

Answer 14

• most stones are radiolucent(cholesterol stones)

- whereas 10-15% are radio-opaque

Question 15

What is the difference between ERCP and MRCP?

Answer 15

-ERCP is used for interventions like stoe removal
MRCP-is only used for diagnostics and does not use contrast but we can view the intrahepatic and extrahepatic as well as the pancreatic duct

Question 16

What conservative Rx can we give he patient?

Answer 16

• dietary changes
• spasmolytics
• analgesia

Question 17

What is the Rx for cholelithiasis?

Answer 17

-laparoscopic cholecystecomy
-indicated when you have symptomatic cholelithiasis
or asymptomatic but at risk for gallbladder cancer

Question 18

What are the complications for cholelithiasis?

Answer 18

1. choledocholiathis
2. cholangitis
3. cholecystitis
4. mirizzi syndrome

Question 19

What is the alternative for patients with cholelithiasis that do not want to get surgery?

Answer 19

• They can medical management called medical/oral litholysis
• for 6 months
• You can consume bile salts

Question 20

How is cholesterol and food items taken into the bile acid?

Answer 20

-bile salts and phospholipids are amphiphatic(both have hydrophillic and hydrophoic elements) that help keep the cholesterol in he vesicles and don’t forge into stones

Question 21

What age do cholesterol stones develop in?

Answer 21

• older
• obese
• rapid weight loss
• developed countries

Question 22

What age do pigment/black stones develop in?

Answer 22

-younger patients

Question 23

How long does biliary colic occur for if we are dealing with symptomatic choleliathis?

Answer 23

-minutes to 2 hours

-

Question 24

What triggers the biliary colic?

Answer 24

• fried oily foods

- after meals

Question 25

What is the criteria for a normal cholangiopancreatogram?

Answer 25

1. normal intrahepatic ducts 2. no filling defects 3. smooth common bile duct 4. good free flow of contrast into the duodenum 5. no strictures or narrowing of the common bile duct

Question 26

What are the 3 ways that patients with gallstones present?

Answer 26

1. asymptomatic 2. symptomatic , uncomplicated 3. symptomatic, complicated

Question 27

What are the two ways that symptomatic patients present with gallstones?

Answer 27

1. Biliary dyspepsia where there is upper abdominal pain, aversion to fatty food and flatulence 2. Biliary colic- right upper quadrant pain which radiates to the right scapula and is colicky(6-8 hours), vomiting and nausea They also have tenderness over the galbladder and we treat with IV spasmolytic

Question 28

Under what special circumstances would we consider surgery for asymptomatic patients?

Answer 28

1. DM 2. >2CM gallstones 3. gallstones in the common bile duct 4. patients who cannot afford a long stay in hospital

Question 29

What surgery do we do for gallstones?

Answer 29

open or laparoscopic cholecystectomy

Question 30

What are the benefits of doing laparoscopic cholecystectomy?

Answer 30

1. shorter hospital stay 2. Better and faster return to baseline 3. superior cosmetic result 4. less post-operative respiratory complications

Question 31

What are the alternatives to gallstone removal that only work on cholesterol stones and can cause recurrence of stones?

Answer 31

1. bile salt oral intake | 2. extracopreal shockwave lithotripsy