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GALL STONES - Coggle Diagram
GALL STONES
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Differential Diagnosis
Acute Hepatitis A, B and C
Bile Duct Stricture, Gallbladder Polyps, Gastritis (Dyspepsia), GORD
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Tumours of gallbladder, liver, stomach, gut and pancreas
One or more conditions may simultaneously occur with gallstones , diagnosing made challenging
Diagnosis
Suspect gallstones with presentation of Biliary Colic pain in epigastrium RUQ lasting > 30mins but < 8hrs associated with nausea/vomiting but not associated with fever/abdominal tenderness.
Acute Cholecystitis - common presentation, symptoms and signs similar to biliary colic with fever and tenderness in RUQ.
Obstructive Jaundice - Yellow discolouration of skin, eyes, dark urine and pale stools.
Cholangitis - fever often with rigors, jaundice and RUQ pain
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Symptoms of complications - fever, hypotension, epigastric pain radiating to back, dark urine, jaundice, Murphy's sign, diffuse abdominal tenderness or bile pigment in urinalysis positive.
Consider gallstones disease in persons with abdominal pain not confirmed with another cause. Gallstones can be dectected on ultrasound or X-ray findings.
Diagnostic Tests
Offer Abdominal Ultrasound exam- the absence of stones on ultrasound scan does not exclude its existence
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Consider Magnetic resonance cholangiopancreatography (MRCP) - if results normal but clinical suspicion remains high, that is if bile duct is dilated despite and ultrasound not detected stones and LFT's deranged.
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Management
Asymptomatic Gallstones
Gallstones in normal gallbladder and biliary tree- reassure, no treatment required unless symptoms develop.
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Asymptomatic gallstones found in bile duct - offer referral for bile duct clearance and laparoscopic cholecystectomy. Risk of complications such as cholangitis/pancreatitis.
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Symptomatic Gallstones
Arrange emergency admission if systemically unwell with suspected complication such as acute cholecystitis/cholangitis/pancreatitis
Refer urgently expertise surgical/ gastroenterology biliary disease- known gallstones/jaundice/suspicion of biliary obstruction e.g. abnormal liber function tests.
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Laparoscopic cholecystectomy as an elective procedure. Percutaneous cholecystostomy to manage gallbladder empyema when surgery contraindicated at presentation and conservative management unsuccessful.
Offer pain relief - severe pain administer parental analgesic for rapid relief. Diclofenac 75mg intramuscularly unless contraindicated. A second 75mg dose give after 30 min if required. Consider intramuscular opioid e.g. morphine/pethidine if diclofenac not suitable.
Intermittent mild/moderate pain - offer paracetamol or NSAID e.g. diclofenac oral/rectal if nausea an issue. If pain not manageable in primary care refer to hospital as emergency.
Consider low fat-diet to prevent biliary pain. If symptomatic gallstones advise to avoid food /drinks triggering symptoms until gallbladder/stones removed. Seek further advice if eating/drinking triggers existing symptoms /causes new symptoms after gallbladder/stones removed.