Gallstones

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