Please enable JavaScript.
Coggle requires JavaScript to display documents.
Gallstones (Biliary Colic & Acute Cholecystitis) (Epidemiology (More…
Gallstones (Biliary Colic & Acute Cholecystitis)
Definitions
Biliary colic
The term is used for the pain associated with the temporary obstruction of the cystic or common bile duct by a stone migrating from the gallbladder
The pain of stone-induced ductular obstruction is of sudden onset, severe but constant and has a crescendo characteristic
Cholecystitis
Gallbladder inflammation
Bile contains cholesterol, bile pigments (broken down Hb) and phospholipids
Epidemiology
More common in Scandinavians, South Americans and Native North Americans but less common in Asian and African groups
Most form in the gallbladder
More common in FEMALES than males
Most are asymptomatic
Increase in prevalence with age
May be present at any age but unusual before 30s
Causes
Diabetes Mellitus
Contraceptive Pill
Obesity and rapid weight loss
Diet high in animal fat and low in fibre
Liver cirrhosis
Risk Factors
Female
Fat
Fertile - more kids = increased risk of gallstones
Smoking
Pathophysiology
Cholesterol gallstone
Cholesterol stone formation due to cholesterol crystallisation in bile
Cholesterol is held in solution by the detergent action of bile salts and phospholipids, with which it forms micelles and vesicles
Main causes are being female, age and obesity
Cholesterol gallstones only form in bile which has an EXCESS of cholesterol, either because there is a:
Relative deficiency in bile salts and phospholipids
Relative excess of cholesterol (supersaturated or lithogenic bile) e.g. in DM or high cholesterol diet
Other factors that determine gallstone formation
Reduced gallbladder motility and stasis e.g. in pregnancy and diabetes
Crystalline promoting factors in bile e.g. mucus and calcium
Most of cholesterol is derived from hepatic uptake from diet
Large stones that are often solitary
Accounts for the majority (80%) of gallstones in the Western world
Bile pigment stones - mainly formed of Ca2+
Main cause is haemolysis
Two main types; black and brown
Small stones that are friable and irregular
Black pigment gallstones
Calcium bilirubinate composition and a network of mucin glycoproteins that interlace with salts e.g. calcium bicarbonate
Glass-like cross-sectional surface
Seen is patients with haemolytic anaemias - chronic excess of bilirubin
Pathogenesis is completely independent of cholesterol gallstones
Brown pigment stones
Composed of calcium salts e.g. calcium bicarbonate, fatty acids and calcium bilirubinate
Muddy hue with an alternating brown and tan layer on cross-section
Almost always found in the presence of bile stasis and/or biliary infection
Common cause of recurrent bile duct stones following cholecystectomy
Two types of gallstone; cholesterol gallstone and bile pigment stones
Clinical presentation
Gallstones DO NOT CAUSE; dyspepsia, fat intolerance, flatulence or other vague upper abdominal symptoms
Biliary or gallstone colic
Term used for the pain associated with the temporary obstruction of the cystic or common bile duct by a stone usually migrating from the gallbladder
Pain is sudden onset, severe but constant and has a crescendo characteristic
Related with the over-indulgence of fatty food
Most common time for onset of symptoms is mid-evening and usually lasts till the early hours of the morning
Radiation of pain may occur over the right shoulder and right sub scapular region
Nausea and vomiting frequently accompany the more severe attacks
Usually epigastrium pain initially but there may be a right upper quadrant component
Once gallstones become symptomatic there is a strong trend towards recurrent complications
Acute cholecystitis - obstruction of gallbladder emptying
Responsible for 95% of cases
Results in increase in gall bladder glandular secretion - progressive distension, may compromise the vascular supply to gall bladder
Also inflammatory response (separates acute cholecystitis from biliary colic) secondary to retained bile within the gallbladder
Initially there is continuous epigastric pain
Progression with severe localised right upper quadrant abdominal pain (parietal peritoneal involvement)
Pain is associated with tenderness and muscle guarding or tightening
Vomiting, fever and local peritonitis
The main difference from biliary colic is the INFLAMMATION
If the stone moves to the common bile duct then obstructive jaundice and cholangitis (inflammation of the bile duct) may occur
Majority of gallstones are asymptomatic
Differentiating colic, cholecystitis or cholangitis
Acute cholecystitis
RUQ pain
Fever/ increased WCC
NO jaundice
Cholangitis
RUQ pain
Fever/increased WCC
Jaundice
Biliary colic
RUQ pain
NO fever/increased WCC
No jaundice
Differential diagnosis
Biliary colic
Irritable bowel syndrome, carcinoma or the right side of the colon, renal colic or pancreatitis
Acue cholecystitis
Acute episodes of pancreatitis, peptic ulceration, basal pneumonia or an intrahepatic abscess
Diagnosis
Acute cholecystitis
Abdominal ultrasound
Pericholecystic fluid
Stones
Thick walled, shrunken gallbladder
Examination
Right upper quadrant tenderness
Murphy's sign: pain on taking a deep breath when examiner plays two fingers on right upper quadrant (location of gallbladder)
Blood tests
Raised serum bilirubin, alkaline phosphatase and aminotransfrase levels
Raised white cell count (due to inflammation) and CRP (C-reactive protein)
Biliary colic
Unlikely to be associated with significant abnormality of laboratory tests
Abdominal ultrasound scan is MOST USEFUL for diagnosing gall stone disease
Treatment
Acute cholecystitis
Opiate analgesia
IV antibiotics - bacteria associated with cholecystitis (Klebsiella, Enterococcus and E.coli)
IV fluids
Cholecystectomy after a few days to allows symptoms to subside
Nil by mouth
Stone dissolution
Give oral ursodeoxycholic acid
Can also give cholesterol lowering agents such as statins
For pure or near-pure cholesterol stones these can be solubilised by increasing bile salt content of bile
Laproscopic cholecystectomy (gallbladder removal)
The treatment of choice for all symptomatic gall bladder stones
Shock wave lithotripsy
Shock wave directed on to gallbladder stones to turn them into fragments so that they can be passed
However the cystic duct requires latency for fragments to pass