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Gallstones

This can be of 3 types:

  • Cholesterol (90%) - Large, yellow stones

  • Pigment/Bilirubinate - Small, pigmented stones

  • Mixed

“Opened gall bladder containing numerous gallstones” © Emmanuelm (Licensed under CC-BY 3.0) https://creativecommons.org/licenses/by/3.0/


Risk factors - 4 F's:

  • Fair

  • Fat

  • Female

  • Forty


Investigations:

  • USS

  • LFTs - Bilirubin, AST/ALT, ALP, GGT

    • Both ALP and GGT will be raised in biliary obstruction

  • Amylase


Biliary Colic

Stone blocks neck of gallbladder or cystic duct, so gallbladder contracts against the obstruction. Patients present with:

  • Colicky RUQ pain (may radiate to back/tip of scapula) that's worse after eating, esp. a fatty meal

  • N+V

  • Murphy’s -ve


Fatty foods tends to be trigger in these patients as, when fat enters the gut, CCK is released from the duodenum, which triggers gallbladder contraction. This is why an important part of management is to avoid fatty foods (prevents CCK release and gallbladder contraction).

“Gallbladder” © BruceBlaus (Licensed under CC-BY 4.0) https://creativecommons.org/licenses/by/4.0/


Acute Cholecystitis

Stone blocks neck of gallbladder or cystic duct for a long period of time, rubbing against and damaging the mucosal lining, leading to inflammation. Patients present with:

  • RUQ/Epigastric pain (radiating to right shoulder tip if diaphragm is irritated)

  • Fever

  • N+V

  • Murphy’s +ve


N.B. To test for Murphy's sign, you palpate the RUQ and ask the patient to breathe in. Pain on inspiration indicates cholecystitis as the gallbladder comes into contact with your hand.

Ascending Cholangitis

Blockage of CBD causing stasis, and bacterial infection of the biliary tree. Patients present with Charcot’s Triad:

  • Fever

  • Jaundice

  • RUQ pain


N.B. Condition can work to present with extra symptoms of hypotension and confusion = Reynold's Pentad.

“Gallstones and Ascending Cholangitis” © BruceBlaus (Licensed under CC-BY 4.0) https://creativecommons.org/licenses/by/4.0/


Patients are investigated with an US and MRCP. Management is with IVF, Abx, ERCP or Cholecystectomy.


Acute Pancreatitis

Stone blocks ampulla of vater, leading to a backup of pancreatic secretions, auto-digestion, and inflammation. Patients present with:

  • Stabbing-like, epigastric pain which radiates to the back and is relieved by sitting forward or lying in foetal position

  • Vomiting


Gallstone Ileus

Rare complication where the gallstone erodes through the gallbladder wall, forming a fistula between it and the small bowl. If a large stone moves through this fistula, it can get trapped in narrow areas of the bowel, leading to small bowel obstruction. This most commonly occurs around the ileo-caecal valve. Imaging will show air in the biliary tree (pneumobilia) and a dilated small bowel.



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