Approach to patient with gall stone

Risk factors
•Obesity, high calories, medications –
cholesterol secretion.
•Px, estrogen, vagotomy, long parenteral
nutrition- bile stasis
•Diverticulosis & hiatal hernia- saints triad
•Ascaris
•Diabetes
•crihosis
Clinical features
Flatulent dyspepsia
•5f, gaseous distension, fat intolerance,
abdominal discomfort, heart burn, belching
Gall stone colic
Pain
colicky, at night, radiate b/n shoulder
blades, associated with vomiting, restlessness,&
sweating.
Tenderness in RUQ
Acute cholecystitis
more prolonged colicky pain in the RUQ
radiating to right shoulder
Fever
Sever nausea and vomiting
Diabetes- clostridia infection
Murphy sign, boas sign, rigidity &guarding in
upper abdomen, vague mass
Chronic cholecystitis
•Fat intolerance
•Murphy sign is positive
cholecystoses
Dyspepsia, upper abdominal discomfort, murphy
sign + ve
Causes of gall stone
• Metabolic
• Infection
• Bile stasis
• Hemolytic anemia
• Saint’s triad
• Parasitic infestation
• Abnormal mucus
• Prophylactic cholecystectomy in
asymptomatic patients with gall stone is rarely
indicated b/c it rarely causes complications
with out previous colic. But
• Elderly diabetic
• In population where malignancy is highest
• Porcelain GB (must)
• Pigment stone contains less than 20%
cholestrol.
Biliary colic
• Colicky (episodic) abdominal pain which is
continuous and lasts for 1-5 hrs. (if >24hrs
suspect acute cholecystitis or impacted stone
in cystic duct) and increase in severity over
the first our.
• Located in epigastrium or RUQ and radiates to
back b/n shoulder blades, even chest
• The pain is sever and comes abruptly at night
or after ingestion of fatty meals.
• Associated with nausea and vomiting.
• b/n attacks the patient feels well.
• RUQ tenderness during episodes of pain.
• Lab tests are normal.
• Atypical presentations are common. Association with
meal is present in only 50%. The pain may primarily
located in back, LUQ or RLQ. In this case conditions
with upper abdominal pain should be sought even in
the presence of gall stone as PUD, GERD, hernia,
irritable bowl syndrome, diverticular disease, liver
disease, renal calculi, pleuritic pain, myocardial pain.
Acute cholecystitis
• The pain is the same as gall stone colic but
prolonged.
• Nausea and vomiting are sever
• Fever
• leukocytosis
• Peritonitis are rare even in perforation b/c of
omentum.
7/20/2014
Complications of gallstones:
1. In the gallbladder
• Chronic cholecystitis
• Biliary colic
• Acute cholecystitis
°
Empyema
°
Biliary peritonitis
°
Abscess
• Mucocele
• Carcinoma of gallbladder
2. In the common bile duct
• Obstructive jaundice
• Cholangitis
• Pancreatitis
3. In the gut
• Gallstone ileus