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