Gallstones are very common topic and are therefore frequently asked in the exams. Majority of them are asymptomatic and which require no treatment. However, they cause a wide range of clinical problems, depending on their position. They are either made up of cholesterol or pigment (bilirubin breakdown products) or a mixture of the two. Most (75%) gallstones are predominantly cholesterol. Pure pigment stones are rare (<10%) Ninety per cent of gallstones are radiolucent, i.e. they do not show on a plain X-ray (unlike renal calculi, of which 90% are radio-opaque).
Predisposing factors to gallstone formaton include:
2. sex (three times more common)
4. age (10% of <50-year-olds have gallstones, and 30% of <70-year-olds),
5. Haemolytic anemia
7. Crohn’s disease.
Some people appear to have a tendency to form gallstones and are said to have ‘lithogenic bile’. People often refer to the typical gallstone patient as 4F which is fat, female, fertile and forty. Ok? So remember that 4F if u cant remember the risk factors
Complications of gallstones can be divided into 3:
1. In the gallbladder
- Chronic cholecystitis
- Biliary colic
- Acute cholecystitis
- Biliary peritonitis
- Carcinoma of gallbladder
- Obstructive jaundice
- Gallstone ileus
Biliary colic is the pain that associated with irritation of the viscera secondary to cholecystitis and gallstones or in a specific terms caused by gallbladder muscle spasms against a stone stuck in the neck of the gallbladder (Hartmann’s pouch) or the cystic duct. It may account for some of the symptoms for chronic cholecystitis. Unlike intestinal colic, the pain was continuous and not in waves. It is usually felt in the epigastrium or right upper quadrant and may radiate around both costal margins and into the back. The pain can be extremely severe and patients may be sweaty, pale and tachycardic because of it. They may also feel nauseated or vomit. They will usually be unable to get comfortable and will prefer to writhe around rather than stay still. Attacks usually last less than six hours and examination is usually otherwise normal. Differential diagnoses include other causes of severe upper abdominal pain, such as perforated peptic ulcer, pancreatitis, ruptured aneurysm, etc. Management involves giving analgesia, investigation to confirm gallstones (ultrasound) and subsequent cholecystectomy in most cases.
At early stage acute cholecystitis may appear to be biliary colic, and indeed many attacks of acute cholecystitis probably start with biliary colic! The exact mechanisms of acute cholescystitis are poorly understood but they said that it are caused by chemical inflammation within an obstructed gallbladder. Bacterial infection probably is a secondary event in about one-third of cases and these may be the ones most likely to develop complications.
Patients will typically have symptoms of severe right upper quadrant or epigastric pain. Like biliary colic, this may radiate around the costal margins or into the back. However unlike biliary colic, patients will prefer to lie still and take shallow breaths (this is now a form of local peritonitis, not colic). They will usually have a temperature and tachycardia, and may also have nausea and vomiting.
Murphy’s sign may be positive and is often asked about in short case. It is elicited by pressing in the right upper quadrant under the costal margin. The patient is then asked to breathe in, and winces or gasps with pain as the gallbladder moves down and hits the examiner’s hand. The test should also be performed in the left upper quadrant to exclude nonspecific reactions due to other pathology.
A mass may be present in the right upper quadrant, but if so this is not usually the gallbladder itself but rather a ‘phlegmon’ (i.e. inflamed andadherent omentum and bowel around the gallbladder).
The most important confirmatory test is an ultrasound scan. US confirm gallstones, showing thickening and oedema of the gallbladder wall and localise the tender spot to the gallbladder itself. It can also exclude dilatation of the common bile duct and other pathology, such as liver masses.
Image through the long axis of the GB (GB) demonstrates the gallbladder neck (red arrow). GB wall thickness is measured between the gallbladder lumen and the hepatic parenchyma (red arrowheads) with normal thickness <3cmOnly very occasionally is a HIDA scan used to help confirm or exclude cholecystitis. The principle of this test is that HIDA (a radioisotope) is taken up by the liver and excreted into the bile. If the cystic duct is patent, it will fill the gallbladder effectively, excluding cholecystitis.
The treatment of acute cholecystitis is initial resuscitation with intravenous
fluids and antibiotics. The patient will normally be kept nil by mouth or on sips of clear fluids, and initial investigations will be arranged, including basic blood tests such as an FBC (usually the white cell count is raised), U & Es, LFTs and amylase (as acute pancreatitis may be a differential diagnosis).
With conservative treatment approximately 80–90% of cases of acute cholecystitis will settle over the next 24–48 h (i.e. the pain settles, the temperature falls and the patient’s abdomen becomes nontender). In about 10% of cases there will not be a prompt resolution of symptoms and signs, and in these cases surgery is usually advised.
Particularly worrying signs are increasing temperature, tachycardia and the onset of increasing tenderness or the signs of peritonitis. These may indicate infarction of the gallbladder (gangrenous cholecystitis) or perforation, which may produce either a local collection or generalised peritonitis. A gallbladder full of pus (empyema of the gallbladder) usually leads to an unwell patient with the signs of sepsis (fever, tachycardia, hypotension, etc.) as well as pain, and tenderness in the right upper quadrant.
More controversial is the question of what to do with patients who do not absolutely require early surgery. Although conventional management is to allow the acute episode to settle down and to readmit the patient for elective cholecystectomy 6–8 weeks later, many surgeons now prefer cholecystectomy in the acute phase. This allows patients to recover quicker and to be spared further episodes of pain. Laparoscopic cholecystectomy can now be carried out in the acute phase by experienced surgeons.
Chronic cholecystitis is a term used to describe symptoms of upper abdominal pain, indigestion, bloating, burping, nausea and occasional vomiting. Sometimes this symptom complex is called flatulent dyspepsia. The patient may describe the symptoms as being precipitated by fatty food (fats stimulate the release of cholecystokinin, which causes gallbladder contractions). There is usually nothing to find on physical examination.
The main differential diagnoses include
1. peptic ulceration
2. hiatus hernia
3. irritable bowel syndrome.
Because gallstones are so common, it's important not to automatically discribe such symptoms to them simply because that gallstones are present on an US scan. A missed peptic ulcer or irritable bowel syndrome will obviously not be helped by unnecessary cholecystectomy! And the patient will continue to get those symptoms. If the symptoms are thought to be arising from the gallbladder and are significant, then the treatment is cholecystectomy, usually laparoscopic.
Attempting to dissolve gallstones using 'bile salt therapy' might be possible for patients with small, noncalcified stones. It also reserved for those who refuse or unfit for surgery. However bear in mind that this treatment is not very successful.
Cholangitis is a condition where there is infection within the biliary tract and it is rare unless there is associated obstruction. This is a demonstration of the surgical principle that obstructed tubes tend to get infected, i.e. appendicitis, pyelonephritis, etc. Cholangitis is clinically manifested by Charcot’s triad of pain, jaundice and rigors (rigors means involuntary shaking in association with pyrexia). It requires prompt diagnosis and treatment, otherwise it can have a high mortality. Treatment consists of resuscitaton with fluids and the administration of intravenous antibiotics. If resolution is not rapid, then attempts to produce biliary drainage, endoscopically, radiologically or surgically, are required.
That's all for today! Happy revising!