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Biliary colic (Risk factors (Obesity, Age, Gender Female, Haemolysis …
Biliary colic
Risk factors
Obesity
Age
Gender
Female
Haemolysis
Pigment stones
Comorbidities
Crohns disease
DM
Smoking
Family history
Ethnicity
Spanish/Native American
Diet
High fat diet
Medication
Somatostatin analogues
GLP1 analogues
Ceftriaxone
Complications
Obstructive jaundice
Blocked CBD and backlog of bile into bloodstream
Manage with ERCP (sphincterotomy), cholecystectomy
Cholangitis
Ascending infection of biliary tree
Acute cholecystitis
Inflammation/infection of gallbladder
Acute pancreatitis
Blocks pancreatic duct
Gallstone ileus
Stone erodes through gallbladder into duodenum,
then may move to terminal ileum and block
See as stone in ileum, pneumobilia, small bowel fluid level
Mirizzi syndrome
Stone in gallbladder presses on bile duct,
causing jaundice
Cholangiocarcinoma
Mucocoele/empyema
Biliary peritonitis
Perforation and infection of peritoneum
Clinical
presentation
1/3 Charcot's triad
Asymptomatic
Pain
Site
: epigastrium, RUQ
Onset
: sudden/acute
Character
: colicky
Radiation
: back, shoulder/subscapular (diaphragm)
Associated:
jaundice, nausea and vomiting
Timing
: intermittent
Exac/relief
: eating/not eating
Severity:
variable
Jaundice
Nausea/vomiting
Pale urine/dark stools
If obstructive
Pathophysiology
Bile formation
Cholesterol, bile pigments (broken down Hb) and phospholipids
Holds cholesterol in solution via detergent action (micelles)
Defect
Altered concentration of bile components results in different stones forming
Types
Excess cholesterol (80%) - cholesterol stone; large, singular
Excess pigment (10%) - pigment stone (bili and Ca);
small, friable, irregular
Mixed stones (10%); also calcium carboinate, phosphate, calcium stearate, protein, cysteine,
Mechanism
Passage of stone into cystic or common bile duct can lodge in the duct causing spasm of the duct (colicky pain)
Pain caused by contraction of the gallbladder, cystic duct or CBD around a gallstone
Definition
Cholelithiasis (gallstone)
Solid deposit that forms in the gallbladder
Cholecystolithiasis
Gallstones in the gallbladder
Choledocholithiasis
Gallstones in the CBD
Epidemiology
Common (10-15%)
Increasing age
F>M
Diagnosis
Examination
**Abdo: no tenderness /guarding
PR: often nil
Investigations
Bloods
FBC (normal WCC), CRP (normal),
LFTs (abnormal if CBD stone), clotting/G+S
Imaging
USS abdo (stones, thick walled gallbladder)
CT abdo (shows stones)
MCRP (location of stones if USS/CT -ve)
ERCP (location and retrieval of stones)
Bedside
Obs (stable, apyrexial)
Urinalysis
Dipstick, MCS (nil)
History
PC/HPC: abdo pain, N+V, jaundice, stools, no fever
PMH: gallstones, medical conditions, previous surgeries
DH: current meds, allergies
FH: gallstones
SH: smoking, diet, exercise, alcohol
Management
Medical
Analgesia
Indication: pain
E.g. diclofenac, paracetamol, opioid
IV fluids
Indication: rehydration
Surgical
Cholecystectomy
Indication: asymtpomatic gallstones in CBD
MOA: asap for acute, or >6w elective;
usually percutaneous, open if perforated
Conservative
Lifestyle (weight loss, diet, exercise, stop smoking)
NBM until senior r/v
Surgical referral
Prognosis
Most people remain symptomatic
Varied prognosis in symptomatic patients
Differentials
Liver/biliary
Infection: hepatitis, cholecystitis, cholangitis, pancreatitis
Trauma: Budd Chiari syndrome
Autoimmune: autoimmune hepatitis
Neoplastic: cholangiocarcinoma, HCC, panc ca
Bowel
Vascular: mesenteric ischemia
Infection:appendicitis, gastroenteritis, gastritis, peptic ulcers
Trauma: obstruction, perforation
Autoimmune: IBD
Idiopathic: GORD
Neoplastic: colorectal ca
Degenerative: diverticular disease
Functional: IBS