Bile contains cholesterol, bile pigments and phospholipids - if concentrations vary stones can form
Pigment stones - small, friable and irregular, caused by haemolysis
Cholesterol - large, often solitary. Associated with F, age and obesity
Occur in 8% over 40, 90% are asymptomatic.
Risks for becoming symptomatic - smoking, parity
Stones may cause;
Acute or chronic cholecystitis
Bilary colic
Pancreatitis
Obstructive jaundice
Acute cholecystitis
Follows stone or sludge impaction in the neck of the gallbladder
May cause continuous epigastric or RUQ pain (referred to right shoulder), vomiting, fever, local peritonism or a GB mass
The main difference from biliary colic is the inflammatory component - local peritonism, fever, raised WCC
If the stone moves to the CBD, obstructive jaundice and cholangitis may result
Murphy’s sign positive - place fingers over RUQ and get patient to breath in, then repeat on the LUQ
Tests - raised WCC, ultrasound - thick walled, shrunken GB, pericholestatic fluid, stones? CBD - dilated >6cm? AXR only shows up 10% of stones
Treatment
NBM, analgesics, IV fluids and antibiotics e.g. cefuroxime
Cholecystectomy
Chronic cholecystitis
Stones causing chronic inflammation and colic
Vague abdo pain, distension, nausea, flatulence and fat intolerance
US used to check for stones and CBD dilation
Treatment - cholecystectomy
Biliary colic
Occurs when gallstones become symptomatic with cystic duct obstruction or by passing into the CBD
Give RUQ pain, radiating to back plus jaundice
Give morphine plus an antiemetic
Elective cholecystectomy
Other presentations
Obstructive jaundice with CBD stones
Cholangitis - bile duct infection
Gallstone ileus - a stone perforates the GB entering the duodenum where it may obstruct the terminal ileum. Duodenal obstruction is rarer - Bouveret’s syndrome
Pancreatitis
Empyema
Complications of gallstones;
In the gallbladder;
Biliary colic
Acute and chronic cholecystitis
Empyema
Mucocoele
Carcinoma
In the bile duct
Obstructive jaundice
Pancreatitis
Cholangitis
In the gut;
Gallstone ileus