Gallstone Disease and management teaching

Gallstone disease overview

1. Gallstones -
An Overview
Ramez Antakia
General Surgery

2. Anatomy

3. Epidemiology
In the adult Western world 15-20% of people
develop gallstones
Majority of patients are asymptomatic at
time of diagnosis of gallstones (70%)
Of those with known Gallstones progression
of asymptomatic to symptomatic disease is
low (10-20%)
Potential to cause Biliary colic, acute or
chronic cholecystitis, Ascending Cholangitis,
pancreatitis, gallstone ileus
Biliary colic is the most common
symptomatic presentation

4. Risk Factors
Risk Factors Classically taught as the 5 F’s
Fair, Fat, Fertile, Female, Forty (plus)
Other risk factors
Positive family history
Sudden weight loss (including post bariatric
surgery)
Loss of bile salts (ileal resection, terminal
ileitis)
Diabetes –as part of metabolic syndrome
Oral contraception

5. Gallstone Composition
Bile contains cholesterol, bile pigments
(from broken down haemoglobin and
phospholipids
4 Main Types
Cholesterol
Black Pigment
Brown Pigment
Mixed

6. Gallstone Composition
Cholesterol Stones
80% if all GB stones in UK
Large, commonly solitary and radiolucent
Black pigment stones
Small, irregular radiolucent
Risk factors include haemolysis and cirrhosis
Brown pigment stones
Less than 5%
Result as stasis and infection within biliary system by E. Coli and/or Klebsiella
Mixed stones
Combination of calcium salts, pigment and cholesterol
10% are radiopaque

7. Presentation
Colicky abdominal pain in the right upper quadrant
May radiate to the back and/or right shoulder tip
May be triggered by fatty foods
Jaundice (conjugated -dark urine and pale stools)
Nausea +/-vomiting
May have Pyrexia
Palpable gallbladder
Murphy’s sign positive
With the patient sat at 45 degrees and hand pressing below the right
ribs at the mid-clavicular line. On inhalation the patient will pause
with discomfort as the gallbladder is pressed against the examiners
hands

8. Differential
Diagnosis
Includes causes of Right Upper
Quadrant/epigastric pain
Biliary colic, cholecystitis,
ascending cholangitis
Hepatitis
Gastric/duodenal ulceration
Reflux/GORD
Pancreatitis
Malignancies of Upper GI tract

9. Investigation
Urinalysis, ECG + Erect CXR
(to exclude other diagnosis)
Biochemical
May be Normal in Biliary Colic
Deranged LFTs
Obstructive pattern (Raised Bilirubin with mainly raised ALP + GGT)
Raised CRP and WCC
Radiological
Ultrasound
Good for visualising stones within gallbladder
CBD dilatation, >7 abnormal
Thickened Gallbladder wall, >3mm abnormal
MRCP -Magnetic Resonance Cholangiopancreatography
better for visualising stones and outlining biliary tree
Higher sensitivity and specificity for detecting gallstones

10. Gallstone Disease Spectrum
Cholelithiasis(presence of gallstones)
Biliary Colic
Gallstone temporarily blocks the bile duct
Pain due gallbladder contraction to clear stone
Acute Cholecystitis
Inflammation of gallbladder due to biliary obstruction and bacterial growth in bile
May progress to Gallbladder empyema
Ascending Cholangitis
Characterised by Charcot’s Triad
1.Right upper quadrant pain
2.Jaundice
3.Fever

11. Gallstone Pancreatitis
Blockage of pancreatic
duct by stone causes
pancreatitis
Gallstone ileus
A fistula between the
gallbladder and
duodenum forms aided
by inflammation
A gallstone passes
through this fistula and
becomes trapped within
the lumen –usually the
terminal ileum
Can cause small bowel
obstruction

12. Treatment
Analgesia, Anti-emetics, IV fluid
Antibiotics
with raised inflammatory markers
based on hospital guidelines
ERCP
Cholecystectomy
May be laparoscopic or Open
Often performed as an Urgent Outpatient Procedure
IR guided Cholecystostomy Drain
Can be used to drain gallbladder empyema
Drain can remain in situ until time of Cholecystostomy

13. Endoscopic Retrograde Cholangio-Pancreatography -
ERCP
Usually performed with
Therapeutic Intent
Endoscope inserted through mouth
to reach the ampulla of Vater
The opening of the ampulla can be
enlarged (sphincterotomy)
A plastic catheter is inserted
through the ampulla and
radiocontrast injected
This allows for visualisation of
stones/strictures
The common bile duct may be
trawled with a basket or balloon to
remove stones

15. References
https://patient.info/doctor/gallstones-and-cholecystitis#ref-7
https://www.nice.org.uk/guidance/cg188
https://www.uptodate.com/contents/gallstones-beyond-the-basics
Standards of Practice Committee of American Society for Gastrointestinal
Endoscopy. ASGE guideline: the role of ERCP in diseases of the biliary tract
and the pancreas.Gastrointest Endosc. 2005 Jul;62(1):1-8.