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Questions and Answers
Which of the following correctly identifies a risk factor for developing gallstones?
What percentage of the adult population is estimated to have gallstones?
Which of the following is a common symptom associated with gallstones?
Which condition refers to the presence of stones in the gallbladder?
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Which of the following is NOT one of the '5 Fs' associated with gallstones?
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What is the most common complication of gallstones when they obstruct the cystic duct?
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Which of the following describes biliary colic?
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What indication suggests the presence of ascending cholangitis?
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What complication is characterized by necrosis of the gallbladder wall?
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Which condition is likely to occur if a gallstone erodes into the duodenum?
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What is the main cause of jaundice in surgical cases related to gallstones?
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What are the key features of acute cholecystitis?
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Charcot's triad is associated with which complication of gallstones?
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What is the most common cause of extra-hepatic obstruction?
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What is a potential consequence of a massive release of cytokines in pancreatitis?
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Which condition involves a stone eroding into the duodenum leading to small bowel obstruction?
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Which of the following is NOT a symptom associated with patients presenting with gallstones?
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Which laboratory investigation is primarily used to assess liver function in patients suspected of gallstone disease?
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What should be done if gallstones are found incidentally and the patient is asymptomatic?
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Which of the following physical exam findings might indicate acute cholecystitis?
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Which imaging technique is often utilized to identify abnormalities related to gallstones?
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What characteristic finding on plain x-ray is associated with gallstone ileus?
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Which of the following is NOT a potential consequence of pancreatitis related to gallstones?
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Which symptom would most likely indicate a complication related to gallstones and warrants further investigation?
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What mechanism leads to pancreatitis in the context of gallstones?
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Which condition involves the formation of a fistula due to gallstones?
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Which factor is least likely to contribute to the development of gallstones?
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Which laboratory test is specifically useful in evaluating damage to pancreatic tissue?
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What is a key clinical hallmark of surgical jaundice in the context of gallstones?
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Which of the following conditions is defined as stones located within the common bile duct?
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What is a common trigger for biliary colic?
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In patients presenting with gallstones, which sign may indicate acute cholecystitis during physical examination?
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Which of the following statements about the demographics of gallstone disease is accurate?
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Which term best describes the obstruction of the intestines due to a gallstone?
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What complication can occur due to a gallstone obstructing the cystic duct?
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Which of the following symptoms is associated with biliary colic?
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What indicates the presence of surgical jaundice?
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In which condition is Charcot’s triad typically observed?
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Which statement accurately describes a complication from a blocked gallbladder neck?
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What is a potential outcome when a gallstone blocks the common bile duct?
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What results from a stone impacting in the cystic duct?
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Which complication is characterized by necrosis of the gallbladder wall?
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Study Notes
Gallstone Disease
- Gallstones form when bile contains too much cholesterol, bilirubin, or not enough bile salts. It is not fully understood why these changes occur.
- Gallstones may also form if the gallbladder does not empty completely or often enough.
- 10% of the adult population have gallstones.
- Females are twice as likely as males to have gallstones.
- Approximately 10% of those with gallstones will become symptomatic.
Risk Factors for Gallstones
-
Gender: females are more likely
-
Obesity
-
Haemolytic disorders
-
Diet: higher prevalence in Western world
-
Medications (clofibrate)
-
Age
-
Fertility
-
Family history
-
The 5 Fs: Female, Fertile, Forty, Fat, Family history
Terms to Understand
- Biliary Colic: RUQ/epigastric pain associated with stones in the bile ducts.
- Chole-lithiasis: Stones in the gallbladder
- Chole-cyst-itis: Inflammation of the gallbladder
- Chole-docho-lithiasis: A stone within the common bile ducts.
- Ascending chol-angitis: Infection of the common bile duct.
- Gallstone ileus: Intestinal obstruction due to a gallstone
Presentation of Gallstones
- Asymptomatic
- Biliary colic
- Cholecystitis
- Gangrene
- Perforation
- Empyema
- Mucoceole
- Ascending cholangitis
- Obstructive jaundice
- Pancreatitis
- Gallstone ileus
Complications of Gallstones
-
Gallstone in the Gallbladder or Cystic Duct
-
Asymptomatic: the majority of cases.
- Can distract from another diagnosis
- Biliary colic: pain without inflammation
-
Cholecystitis: infection in the GB
- 80% of cases are due to obstruction of the cystic duct by a gallstone.
- Can progress to:
- Empyema: pus in the gallbladder
- Gangrene: necrosis of the wall
- Perforation
- May settle down to:
- Chronic Cholecystitis or Mucoceole: stone impacted in cystic duct
- Stone can erode into the duodenum causing small bowel ileus
-
Asymptomatic: the majority of cases.
-
Gallstone in the Common Bile Duct
- Ascending cholangitis: infection
- Pancreatitis: inflammation
- Jaundice: obstruction
Complications of Gallstones - Continued
-
Biliary Colic
- Stone in the gallbladder or GB neck.
- Pain (RUQ +/- epigastric)
- Waxing and waning pain
- Radiates to the scapula (Collins sign)
- Usually occurs within an hour of eating (food stimulates CCK secretion from the duodenum - GB contractions)
- Few abdominal signs
-
Acute Cholecystitis
- Stone blocking the GB neck
- Constant RUQ pain
- May radiate to the right scapula (Collin's sign)
- Pain worsens on deep breathing
- Fever
- Nausea and anorexia
- Tenderness, guarding & Rebound RUQ
- Murphys sign +
-
Ascending Cholangitis
- Stone in the common bile duct
- Charcot's triad:
- Intermittent RUQ pain
- Intermittent Fever
- Intermittent Jaundice
- May have dark urine and pruritus.
- RUQ tenderness
- Risk factors: over 50 years of age, cholelithiasis, injury or stricture of bile ducts
-
Surgical Jaundice
- Definition: Jaundice due to intra- or extra-hepatic obstruction to bile.
- Biliary obstruction - blockage of any duct carrying bile from the liver to the duodenum.
- Most surgical causes are hepatic and post hepatic
- Gallstones are the most common cause of extra-hepatic obstruction.
- Other causes include:
- Malignancy
- Inflammation (pancreatitis)
- Primary Sclerosing Cholangitis (PSC)
- Merrizi's Syndrome.
-
Pancreatitis
- Stone blocking the Ampulla of Vater
- Bile forced up the pancreatic duct causing inflammation and injury to the pancreas
- Release of digestive enzymes locally and into the bloodstream.
- Massive release of cytokines
- "Cytokine Storm" is a possible consequence
- All body organs can be affected
- Lungs (blood oxygen falls)
- Kidneys (urea level rises)
- Pancreatic islets (blood sugar rises)
-
Gallstone Ileus
- Stone erodes into the duodenum
- Fistula between the gallbladder and duodenum
- Uncommon and mainly affects elderly women.
- Small bowel obstruction
- Air in the biliary tree on plain x-ray.
Patient Presenting with Gallstones
-
History
- Site and nature of pain are essential (usually RUQ)
- Associated symptoms (nausea and vomiting)
- Jaundice
- Pale stools, dark urine & pruritus
- Rigors
- Risk factors
Physical Examination
-
Look for:
- Jaundice
- Pyrexia
- Scratch marks
- Murphy's Sign (acute cholecystitis)
- Refer to links for Murphys sign
- https://www.youtube.com/watch?v=2T0XUQ1M-x0
- https://www.youtube.com/watch?v=9L7N89sOSuc
Workup
-
Bedside Investigations
- Physical Examination (including vitals)
- ECG
- Urine dipstick & Beta-hCG
- Glucose check
-
Laboratory Investigations
- Full Blood Count (FBC)
- Liver function tests (LFTs) - bilirubin, AST/ALT, alkaline phosphatase
- C-reactive protein (CRP)
- Amylase
- Coagulation Screen
- ABG/VBG
- Lactate
-
Imaging
- Erect CXR
- US abdomen
- MRCP
- ERCP
- Endoscopic ultrasound
Management of Gallstone Disease
-
Asymptomatic Gallstones*
-
Asymptomatic gallstones may be discovered incidentally.
-
Patient must be fully informed of potential complications of gallstones and of surgery.
-
Symptomatic Gallstones*
-
Depends on the presentation of the patient
-
Patient's medical history
-
Patient's physical examination
-
Results of investigation
Gallstones & Surgical Jaundice
- Gallstones form when bile contains too much cholesterol, bilirubin, or not enough bile salts.
- The exact reasons for these changes in bile are not completely understood.
- Gallstones can also form if the gallbladder doesn't empty completely or frequently enough.
- Approximately 10% of the adult population has gallstones.
- Females are twice as likely as males to develop gallstones.
- Roughly 10% of people with gallstones will experience symptoms.
Risk Factors for Gallstones
- Gender: Females are more likely to develop gallstones due to hormonal factors.
- Obesity: Excess cholesterol in bile can contribute to gallstone formation.
- Hemolytic Disorders: Increased bilirubin production can lead to gallstones.
- Diet: Western diets, high in fat and cholesterol, may increase the risk.
- Medications: Some drugs, like clofibrate, can affect bile composition.
- Age: The risk of gallstones increases with age.
- Fertility: Gallstones are more common in women who have had children.
- Family History: A family history of gallstones increases the risk.
- "The 5 Fs": Female, Fertile, Forty, Fat, Family history
Terms related to Gallstones
- Biliary Colic: Pain in the upper right abdomen (RUQ) or epigastric region associated with gallstones in the bile ducts.
- Cholelithiasis: Gallstones in the gallbladder.
- Cholecystitis: Inflammation of the gallbladder.
- Choledocholithiasis: A gallstone in the common bile duct.
- Ascending Cholangitis: Infection of the common bile duct.
- Gallstone Ileus: Intestinal obstruction caused by a gallstone.
Presentation of Gallstones
- The symptoms depend on the location and behavior of the gallstones.
- Asymptomatic: Most gallstones do not cause symptoms.
- Biliary Colic: Pain usually in the RUQ, can radiate to the scapula.
- Cholecystitis: Inflammation of the gallbladder, characterized by constant, severe pain.
- Gangrene: Death of gallbladder tissue.
- Perforation: A hole in the gallbladder wall.
- Empyema: Pus in the gallbladder.
- Ascending Cholangitis: Infection of the common bile duct, often causing fever, jaundice, and pain.
- Obstructive Jaundice: Yellowing of the skin and eyes due to blockage of bile flow.
- Pancreatitis: Inflammation of the pancreas.
- Gallstone Ileus: Intestinal obstruction due to a gallstone.
Complications of Gallstones
-
Gallstone in the Gallbladder or Cystic Duct:
- Asymptomatic: Most common, but can be misdiagnosed as other conditions.
- Biliary Colic: Pain without inflammation.
- Cholecystitis: Inflammation of the gallbladder – often due to obstruction of the cystic duct by a gallstone.
- Progression: Can lead to empyema, gangrene, or perforation.
- Chronic Cholecystitis or Mucoceole: Inflammation or fluid buildup in the gallbladder due to a stone in the cystic duct.
- Gallstone Ileus: A gallstone can erode into the duodenum and cause intestinal obstruction.
-
Gallstone in the Common Bile Duct:
- Ascending Cholangitis: Infection of the common bile duct.
- Pancreatitis: Inflammation of the pancreas.
- Jaundice: Yellowing of the skin and eyes due to bile duct blockage.
Complications in Detail
-
Biliary Colic:
- Pain in the RUQ or epigastric region, often radiating to the scapula.
- Pain can worsen after eating, as food stimulates gallbladder contraction.
- Usually lasts less than an hour.
- Minimal abdominal signs.
-
Acute Cholecystitis:
- Constant pain in the RUQ, often radiating to the right scapula.
- Pain worsens with deep breathing.
- Fever, nausea, and anorexia are common.
- Tenderness, guarding, and rebound tenderness in the RUQ.
- Positive Murphy's sign (pain on palpation of the gallbladder).
-
Ascending Cholangitis:
- Characterized by Charcot's triad:
- Intermittent RUQ pain.
- Intermittent fever.
- Intermittent jaundice.
- Can also cause dark urine, itching (pruritus), and RUQ tenderness.
- Risk factors include age over 50, cholelithiasis, and bile duct injury or stricture.
- Characterized by Charcot's triad:
-
Surgical Jaundice:
- Jaundice caused by obstruction of bile flow from the liver to the duodenum.
- Most surgical causes are hepatic (liver) or post-hepatic (after the liver).
- Gallstones are the most common cause of extra-hepatic obstruction.
- Other causes include malignancy, inflammation, primary sclerosing cholangitis, and Mirizzi's syndrome.
-
Pancreatitis:
- Gallstone obstructing the Ampulla of Vater (common bile duct and pancreatic duct junction).
- Bile backs up into the pancreatic duct causing inflammation and damage.
- Release of digestive enzymes can cause local and systemic inflammation.
- "Cytokine storm" can affect multiple organs, including lungs, kidneys, and pancreas.
-
Gallstone Ileus:
- Gallstone erodes into the duodenum creating a fistula between the gallbladder and duodenum.
- Uncommon, but more likely in elderly women.
- Causes small bowel obstruction.
- Air in the biliary tree may be visible on an X-ray.
Workup for Possible Gallstones
-
History:
- Location and nature of pain (usually RUQ).
- Associated symptoms (nausea, vomiting, jaundice).
- Pale stools, dark urine, and pruritus (itching).
- Rigors (shivering)
- Risk factors.
-
Physical Exam:
- Jaundice.
- Pyrexia (fever).
- Scratch marks (due to itching).
- Murphy's Sign (acute cholecystitis).
-
Investigations:
-
Bedside:
- Physical exam (including vitals).
- ECG.
- Urine dipstick and beta-hCG.
- Glucose check.
-
Laboratory:
- Full Blood Count (FBC).
- Liver function tests (LFTs) - bilirubin, AST/ALT, alkaline phosphatase.
- C-reactive protein (CRP).
- Amylase.
- Coagulation screen.
- ABG/VBG (blood gases).
- Lactate.
-
Imaging:
- Erect chest X-ray (CXR).
- Ultrasound (US) of the abdomen.
- Magnetic Resonance Cholangiopancreatography (MRCP).
- Endoscopic Retrograde Cholangiopancreatography (ERCP).
- Endoscopic ultrasound.
-
Bedside:
Management of Gallstone Disease
-
Asymptomatic Gallstones:
- May be discovered incidentally during other procedures.
- Patients should be informed about the potential complications of gallstones and surgery.
-
Symptomatic Gallstones: -Treatment options depend on the severity of symptoms and specific complications.
- Cholecystectomy (gallbladder removal): The most common treatment when symptoms are present or if complications arise. This can be done laparoscopically or with open surgery.
- Medications: Can be used to dissolve gallstones (limited effectiveness) or relieve symptoms like pain.
- ERCP: Used to remove gallstones from the common bile duct.
- Drainage of the gallbladder: For patients who are not suitable for surgery.
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Description
Test your knowledge of gallstone disease, including the causes, risk factors, and terminology associated with this condition. Understand the symptoms and learn about the implications of gallstone formation in the body. This quiz aims to provide a comprehensive understanding of gallbladder health.
