Gallstones Pathologies

Gallstones Pathologies Risk factors 6Fs Female Fair Forty Fertile Family history Fat/obese and insulin resistance Types Type Description Gallstone in bile duct Temporary severe pain After meals (esp. fatty meals) -> CCK -> gallbladder contraction -> gallstone lodged into cystic duct -> sudden dull pain in RUQ and/or epigastrium -> radiates to right shoulder Biliary Colic Pain increases for 15 minutes and then a steady plate for a few hours (less than 6hours) -> gallstone dislodges and goes back to gallbladder -> pain decreases If does not dislodge and stays for longer -> acute cholecystitis Several hours after a meal Can happen at night since lying flat makes it easy for the gallstone to dislodge Symptoms Nausea, vomiting and sweating Stones in the gallbladder Cholesterol stones Most common Precipitated by cholesterol -> 75 to 90% of cases Can happen when: Bile supersaturation with cholesterol -> more than what bile acids and salts can keep cholesterol in solution Not enough bile acids and salts to keep cholesterol in solution Gallbladder stasis Cannot be seen on X-ray But if have enough CaCO3 may be seen on X-ray (radio opaque) -> but usually not enough -> so radiolucent Are rarely only made up of only cholesterol Bilirubin stones Pigmented Mainly from bilirubin (unconjugated) Also have calcium Cholelithiasis Hence radiopaque Black pigmented stones Chronic haemolytic anaemias Alcoholic cirrhosis TPN Crohn’s disease Advanced age Mixed/brown Bacterial infections and parasites Clonorchis sinensis, Opisthorchis species Clinical features Most are asymptomatic Biliary colic: dull RUQ pain -> lasts more than 6 hours Especially after food Gallstones in the common bile duct Primary and secondary forms Secondary is more common May also have postcholecystrctomy form Characteristic clinical features RUQ pain Choledocholithiasis More severe and prolonged Postprandial May radiate to epigastrium, right shoulder and back -> referred pain Nausea, vomit and anorexia Extra-hepatic features of cholestasis: Jaundice, pale stools, dark urine and pruritus Cystic duct obstruction Inflammation Most commonly acute calculous Rarely acalculous Most common complication of cholelithiasis Clinical features: More severe pain than biliary colic Cholecystitis More than 6 hours Post meals Radiation to scapula -> due to referred pain from phrenic nerve irritation Murphy’s sign: sudden pause in inspiration upon deep palpation of RUQ due to pain May be falsely negative in patients over 60 Guarding Fever, malaise, anorexia Nausea and vomit Bacterial infection of the biliary tree Usually secondary to choledocholithiasis (most common) Biliary strictures Congenital Infections e.g. HIV Inflammatory Iatrogenic Acute pancreatitis Contamination of bile with intestinal contents Ascending Cholangitis Clinical features Charcot’s triad -> in 25 to 70% of patients have all three features High fever RUQ pain Jaundice Raynolds pentad: chronic cholangitis + HoTN + mental status changes Features of sepsis, septic shock and multiorgan dysfunction Elderly patients may have non-specific features such as confusion Pain and jaundice may be absent May have atypical presentation High index of suspicion is required to avoid diagnosis and treatment delays Read more on management of gallstone ileus Complications Sepsis Septic shock MODs Pyogenic liver abscess Biliary stricture Gallstone ileus -> bowel obstruction Gangrenous gallbladder Fistula formation