GALLSTONESBy: Anika Khan

Role #1030

ANATOMY OF GALLBLADDER AND EXTRAHEPATIC BILIARY TREE

• Bile • Helps the body digest

fats• Made in the liver• Stored in the gallbladder

until the body needs it• Contains:

• Water• Cholesterol• Bile pigments• Phospholipids• Bicarbonate• Anions of the bile acids

• Concentrations vary - different kinds of stones may be formed

What are gallstones?

• Small hard deposits that form in the gallbladder

• Process of gallstone formation is known as cholelithiasis

• range in size from a few millimeters to several centimeters in diameter• -Pigment stones,

cholesterol stones, mixed stones

pathophysiology

• When bile is concentrated in the gallbladder, it can become supersaturated with these substances, which then precipitate from solution as microscopic crystals. The crystals are trapped in gallbladder mucus, producing gallbladder sludge.

• Over time, the crystals grow, aggregate, and fuse to form macroscopic stones. Occlusion of the ducts by sludge and/or stones produces the complications of gallstone disease.

Signs/symptoms

• About 90% of gallstones cause no symptoms

• Pain in the RUQ• Most common and typical symptom• May last for a few minutes to several hours• Mostly felt after eating a heavy and high-fat meal

• Pain under right shoulder when lifting up arms

• Fever, nausea and vomiting

• Jaundice (obstruction of the bile duct passage)

• Acute pancreatitis (gallstone enters the duct leading to pancreas and blocks it)

• Also need to rule out:• Appendicitis, renal colic, pneumonia or pleurisy,

pancreatitis

causes

• Bile contains too much cholesterol—excess cholesterol may form into crystals and eventually into stones

• Bile contains too much bilirubin—certain conditions cause your liver to make too much bilirubin, including liver cirrhosis, biliary tract infections and certain blood disorders.

• Your gallbladder doesn’t empty cholesterol—bile may become very concentrated and this contributes to the formation of gallstones.

management

• Management depends on the stage

• Treatment for asymptomatic gallstones—medical dissolution for gallstones is recommended--Months or years of treatment may be necessary before all stones dissolve

-25% of patients develop symptoms within 10 years

• Treatment for symptomatic gallstones—cholecystectomy recommended, open versus laproscopic cholecystectomy, cholecystosomy, Endoscopic retrograde sphincterotomy,

• Contact dissolution therapy • Experimental procedure• Involves injecting a drug directly into the gallbladder to

dissolve cholesterol stones

complications

• Inflammation of the gallbladder—cholecystitis

• Blockage of the common bile duct—jaundice and bile duct infection can result.

• Blockage of the pancreatic duct—gallstone can cause a blockage in the pancreatic duct, which can lead to inflammation of the pancreas (pancreatitis

• Gallbladder cancer—rare

• In the GB:• Biliary colic• Acute and chronic

cholecystitis• Empyema• Mucocoele• Carcinoma

• In the bile ducts:• Obstructive jaundice• Pancreatitis• Cholangitis

• In the gut:• Gallstone ileus

diagnosis

• Physical exam includes—Murphy’s Sign

• Abdominal Radiography—exclude other causes of abd pain

• Ultrasound• Most sensitive and specific test for

gallstones

• Computerized tomography (CT) scan • May show gallstones or complications,

such as infection and rupture of GB or bile ducts

• Cholescintigraphy (HIDA scan) • Used to diagnose abnormal contraction

of gallbladder or obstruction of bile ducts

• Endoscopic retrograde cholangiopancreatography (ERCP) • Used to locate and remove stones in

bile ducts

-Blood tests—include CBC, liver function panel, amylase, lipase

Case study

• 46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now.

• No prior episodes

• Minimal RUQ tenderness, no Murphy’s

• WBC 8, LFT normal

• RUQ U/S reveals cholelithiasis without GB wall thickening or pericholecystic fluid

• Diagnosis: ?

diagnosis

→ denotes gallstones

► denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone

references

• http://www.medscape.com/viewarticle/781782_2

• http://emedicine.medscape.com/article/175667-treatment#aw2aab6b6b3

• http://www.mayoclinic.org/diseases-conditions/gallstones/basics/tests-diagnosis/con-20020461

• www.emedicinehealth.com