Gallstones

Gallstone disease occurs when hard fatty or mineral deposits 
( gallstones ) form in the gall bladder

Epidemiology-Very common – 5-30 % of adults in W Europe
UK around 10-15 % Most people are asymptomatic ( ~ 90 % unaware carriers )
Majority of gallstones are cholesterol – main component Substantial economic burden to health-care systems globally Most common GI disease that requires hospitalization


Cause –Gallstone formation is multifactorial including a complex interplay pf sex-specific , genetic, lifestyle and co-morbidity associated factors Cholesterol stones- alteration in the balance between pronucleating factors and antinucleating factors in the bile Factors contributing include 
increased bile cholesterol saturation , impaired gallbladder motor function, changes in enterohepatic circulation Haemolysis / Chronic bacterial or parasitic infestations can lead to pigment stones ( preventable )

Risk factors – Increasing age Female sex Pregnancy High dose oestrogen 
treatment
eg use of COCP, HRT Ethnicity Genetic traits Obesity Crohns disease Testosterone Rx in ♂ Smoking, alcohol Acromegalic patients 
undergoing Rx with
 somatostatin
analogues. High serum triglyceride levels Low HDL Rapid weight loss High calorific diet Refined carbohydrate diet Lack of physical activity Cirrhosis Gallbladder stasis Haemolysis Chronic bacterial or parasitic infection Type 2 diabetes ( x2 ↑ common ) Loss of bile salts- eg ileal resection , terminal ileitis

Asymptomatic gallstones- Usually an incidental finding Distinction between asymptomatic and symptomatic disease can be difficult Biliary colic is a fairly reliable indicator of symptomatic gallstones.Normal gallbladder and normal biliary tree-reassure
○ v common
○ No treatment indicated
○ No prophylactic measure needed 
○ explain possible symptoms and when to seek help
 CBD stones – risk of potential severe complications -REFER ALL

Biliary colic –Most common classical presentation Starts abruptly , pain moderate to severe in nature Pain usually steady than a series of waves as the term implies Pain in upper abdomen or RUQ lasting more 30 min but less than 6-8 hrs Pain not affected by
○ movement
○ body position
○ defecation Associated with nausea and vomiting Not associated with fever or abdominal tenderness Resolves spontaneously Happens when stones enter cystic duct or CBD and the GBl contracts ( for eg after a meal )

Biliary colic
No lab changes
Total bilirubin , amylase / lipase – normal
US – indicating gallstone without findings of cholecystitis.Attacks usually self limiting Mild attacks can be managed in primary care with adequate analgesia ( eg paracetamol , NSAIDs )
consider rectal dilcofenac if nausea problematic Advise low fat diet 
○ fat stimulates cholecystokinin release which precipitates gall bladder contraction Hyoscine and PPIs -> no evidence of use No evidence of benefit from non-surgical treatments eg
○ gall stone dissolution
○ ursodeoxycholic acid
○ extracorporal lithotripsy


Acute cholecystitis –Most frequent complication of symptomatic cholelithiasis Distension of the GBl with subsequent necrosis and ischaemia of the mucosal wall In addition to features of biliary colic
○ raised temperature
○ tachycardia
○ tenderness in RUQ Complications
gangrenous cholecystitis
gallbladder perforation The famous Murphy’s sign has sensitivity of 65 % and specificity of 85 %.Acute cholecystitis
Leukocytosis common
Tot bilirubin N or mildly ↑↑
Amylase and lipase usually N
US -thickened GB wall 
( > 4 mm ) , enlarged GB, fluid collection around GB

Chronic cholecystitis –Results from recurrent or relapsing bouts of acute cholecystitis. Can lead to rare complications as
○ Mirizzi syndrome -obstructive jaundice due to a large stone getting impacted in Hartman’s pouch
○ Gallstone ileus- mechanical obstruction due to impaction of a large gallstone at the IC valve
○ Gallbladder cancer -after long term cholelithiasis. Often asymptomatic.

Choledocholelithiasis- migration of gallstones from GBl to the CBD.
Main implications are. Ascending cholangitis-Can be fatal Typical features- Charcots triad-
○ fever 
( often with rigors )
○ jaundice
○ upper quadrant abdominal pain.

Cholangitis
Elevated bilirubin
Leukocytosis
Amylase/ Lipase usually N or mildly elevated
US- CBD dilatation Obstructive jaundice-Bile duct stone obstructs flow of bile into duodenum Presentation is with biliary colic accompanied by jaundice , dark urine , pale stools and pruritus. Acute pancreatitis-Temporary obstruction to the pancreatic duct during the passage of a bile duct stone via the ampulla of Vater into the duodenum Epigastric pain radiating to back and vomiting.Gallstone pancreatitis
N or ↑↑ bilirubin
3 x times ↑↑ amylase
ALT ↑↑ 150 suggests biliary cause

Investigations-LFT FBC , CRP, Us and Es Amylase , lipase Urine dipstick Ultrasound 1st line
90 % sensitivity and 88 % specificity
Inexpensive , no radiation exposure CT if negative or equivocal US or if complications of gallstone suspected MRI- will detect bile duct stones in ~ 90 % of pts with choledocholelithiasis HIDA ( Hepatobiliary iminodiacetic acid ) scan – functional study that evaluates cystic duct obstruction ( also known as cholescintigraphy or a hepatobiliary scan ) MRCP- Magnetic resonance cholangiopaancretography – 
( if choledocholilithiasis suspected ) non invasive with sensitivity of 92 % and specificity
 of 97 % Endoscopic ultrasound scan – for suspected choledocholilithiasis that is not confirmed by US and patient cannot undergo MRCP for any reason Endoscopic retrograde cholangiopancreatography ( ERCP ) -preferred intervention for patients with high risk of bile duct stones -> obstructing stones can also be removed

Ultrasound-gold standard can detect 95 % of gallstones identify complications occasionally biliary sludge becomes more difficult as BMI ↑↑ and with ↑↑ ed bowel gas request if gallstone suspected.

Choledocholilithiasis
Bilirubin ↑↑
Amylase/Lipase usually N
CBD dilatation


Differential diagnosis-Peptic ulcer disease Gastritis Acalculous cholecystitis (seen sometimes in very ill inpatient eg ICU- often with diabetes, Caused by ischaemia and a degree of acute gallbladder distension associated with fasting ) Irritable bowel syndrome GORD Pancreatitis from other causes 
( eg alcohol ) Tumours of gallbladder , liver ,stomach, gut and pancreas Acute hepatitis Inflammatory bowel disease Sphincter of Oddi dysfunction Bile duct stricture

Other complications-Mucocele of gallbladder Empyema Gangrene Biliary peritonitis Porcelain gall bladder Gall bladder cancer

Admit if systemically unwell with suspected complications as
○ acute cholecystitis
○ cholangitis
○ pancreatitis Refer suspected symptomatic gallstones 
( urgency based on cl judgement ) Refer if US negative but symptoms consistent with gallstone disease Gallstone + jaundice or suspicion of biliary obstruction for eg sig abnormal LFTs -> refer urgently Gallstone + h/o acute pancreatitis- > refer urgently

Cholecystectomy is the definitive treatment irrespective of type of stone Usually performed laparoscopically – day case x 4 incisions < 1 cm each with low risk of complications Bile duct injury is a serious complication
( although low rates < 0.5 % ) Dietary adv following op – no strong evidence
○ some may develop fat intolerance -> adv low fat diet ( BMJ )
○ No dietary restrictions following op ( NICE)
 Options for symptomatic GB stone and CBD stones
○ open cholecystectomy + open exploration of CBD
○ lap cholecystectomy + lap expl of CBD
○ lap cholecystectomy + endoscopic sphincterectomy Percutaneous cholecystectomy if unfit for above Natural orifice transluminal endoscopic surgery- evolving

References
 Biliary pain-Work-up and management in general practice AFP Volume 42 , No 7 , July 2013 Clinical Review Gallstones BMJ 2014 ;348:g2669 Gallstone disease : diagnosis and management NICE CG 188 October 2014 Biliary colic and complications from gallstones accessed via
https://bpac.org.nz/BPJ/2014/june/docs/BPJ61-gallstones.pdf Surgical and Nonsurgical Management of Gallstones Sherly Abraham MD et al AFP BMJ Best Practice Cholelithiasis Incidence of gallstone disease and complications Shabanzadeh et al Current Opinion in Gastroenterology Issue : Volume 34 (2), March 2018, p81-89 Evaluation and Management of Gallstone-Related Diseases in Non-Pregnant Adults- Guideline for Clinical Care Inpatient University of Michigan Gallstones -CKS NHS february 2015 Gallstones and Cholecystitis by Dr Nick Imm et al Patient UK


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