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Gallstone Disease and Acute Cholecystitis
Gallstone Disease and Acute Cholecystitis
Types of gallstone
Cholesterol stones (20%)
Pigment stones (5%)
Mixed (75%)
Epidemiology
Fat, Fair, Female, Fertile, Fourty inaccurate, but
reminder of the typical patient
F:M = 2:1
10% of British women in their 40s have gallstones
Genetic predisposition ask about family history
Composition of bile:
Bilirubin (by-product of haem degradation)
Cholesterol (kept soluble by bile salts and lecithin)
Bile salts/acids (cholic acid/chenodeoxycholic acid):
mostly reabsorbed in terminal ileum(entero-hepatic
circulation).
Lecithin (increases solubility of cholesterol)
Inorganic salts (sodium bicarbonate to keep bile
alkaline to neutralise gastric acid in duodenum)
Water (makes up 97% of bile)
Cholesterol
Imbalance between bile salts/lecithin and cholesterol allows
cholesterol to precipitate out of solution and form stones
Pigment
Occur due to excess of circulating bile pigment (e.g.
Heamolytic anaemia)
Mixed
Same pathophysiology as cholesterol stones
Other Factors
Stasis (e.g. Pregnancy)
Ileal dysfunction (prevents re-absorption of bile salts)
Obesity and hypercholesterolaemia
80% Asymptomatic
20% develop complications and do so on
recurrent basis
Biliary Colic
Acute Cholecystitis
Gallbladder Empyema
Gallbladder gangrene
Gallbladder perforation
Obstructive Jaundice
Ascending Cholangitis
Pancreatitis
Gallstone Ileus (rare)
FBC
LFT
CRP
Clotting
Amylase
Complication
History
Examination
Blood tests
Biliary Colic
- Intermittent RUQ/epigastric
pain (minutes/hours) into
back or right shoulder
- N&V
-Tender RUQ
-No peritonism
-Murphys
-Apyrexial, HR and BP (N)
Acute Cholecystitis
-Tender
RUQ
RUQ
(guarding/rebound)
-Murphys +
-Pyrexia, HR ()
-WCC
-Periotnism
-LFT
-Tender
RUQ
RUQ
-Murphys +
-Pyrexia, HR (), BP ( or )
-More septic than acute
cholecystitis
-WCC
-Peritonism
-LFT
-Yellow
discolouration
stool, dark urine
-painless or assocaited with
mild RUQ pain
-Jaundiced
-WCC
-Pale
-Non-tender
Becks triad
-RUQ pain (constant)
-Jaundice
-Rigors
-Jaundiced
-Tender RUQ
-Peritonism RUQ
-Spiking high pyrexia (38-39)
-HR (), BP ( or )
-Can develop septic shock
-WCC
Acute Pancreatitis
-Severe
upper abdominal
pain (constant) into back
-Profuse vomiting
Gallstone Ileus
Empyema
Obstructive Jaundice
Ascending Cholangitis
or minimally
tender RUQ
-No peritonism
-Murphys
-Apyrexial, HR and BP (N)
and CRP ()
(N or mildly ()
and CRP ()
(N or mildly ()
and CRP ()
: obstructive pattern
bili (), ALP (), GGT (),
ALT/AST ()
-INR ( or )
-LFT
MRCP: To visualise biliary tree accurately (much more accurate than USS)
PTC
CT: Not first line investigation. Mainly used if suspicion of gallbladder empyema, gangrene,
or perforation and in acute pancreatitis (USS not good for looking at pancreas)
Pathogenesis
Stone intermittently obstructing cystic duct
(causing pain) and then dropping back into
gallbladder (pain subsides)
USS confirms presence of gallstones
Treatment
Analgesia
Fluid resuscitation if vomiting
If pain and vomiting subside does not need
admitting
Pathogenesis:
Empyema of gallbaldder
Gangrene of gallbladder (rare)
Perforation ofgallbaldder (rare)
Treatment
Pathogenesis:
Stone obstructing CBD (bear in mind there are other causes for obstructive
jaundice) danger is progression to ascending cholangitis.
USS
MRCP
ERCP
If confirmed stone in CBD on USS or MRCP proceed to ERCP which will confirm this
(diagnostic) and allow extraction of stones and sphincterotomy (therepeutic)
Treatment
Must unobstruct biliary tree with ERCP to prevent progression to ascending
cholangitis
Whilst awaiting ERCP monitor for signs of sepsis suggestive of cholangitis
Pathogenesis:
Stone obstructing CBD with infection/pus
proximal to the blockage
Treatment
ABC
Fluid resuscitation (clear fuids and IVF, catheter)
Antibiotics (Augmentin)
HDU/ITU if unwell/septic shock
Pus must be drained* - this is done by
decompressing the biliary tree
Urgent ERCP
Urgent PTC if ERCP unavailable or unsuccesful
Pathogenesis
Obstruction of pancreatic outflow
Pathogenesis:
Gallstone causing small bowel obstruction (usually obstructs in terminal
ileum)
Gallstone enters small bowel via cholecysto-duodenal fistula (not via CBD)
AXR dilated small bowel loops
May see stone if radio-opaque
Treatment
NBM
Fluid resuscitation + catheter
NG tube
Analgesia
Surgery (will not settle with conservative management) enterotomy +
removal of stone
Diagnosis of gallstone ileus usually made at the time of surgery.
Indications
A single complication of gallstones is an indication for
cholecystectomy (this includes biliary colic)
After a single complication risk of recurrent
complications is high (and some of these can be life
threatening e.g. cholangitis, pancreatitis)
Advantages:
Less post-op pain
Shorter hospital stay
Quicker return to normal activities
Disadvantages:
Learning curve
Inexperience at performing open cholecystectomies
Questions?