GallStones

 
 
1.   Gallbladder  compound  :  
•   70%  Bile  salt  +  acid  
•   10%  Cholesterol  
•   5%  Lethicin  (phospholipids)  
•   5%  Proteins  
•   1%  Bilirubun  
•   ~%  Water,  Electrolyte,  
Bicarbonate  
 
2.   Etiology   Admirand’s  Triagle>>  
•   Cholesterol  Stone    
o   75-­‐90%  of  cases  
o   Percipitation  of  
Cholesterol  because  bile  is  not  sufficient  to  hold  cholesterol  anymore  
in  the  solution  
o   Cause  
§   Increase  in  Cholesterol  or  
§   Decrease  in  Bile  Salt  or  
§   Stasis  
o   Usually  radiolucent  (Cholesterol  precipitation  only)  but  if  there’s  a  lot  
of  precipitation  of  CaCO3  +  Cholesterol  =  radiopaque  
o   Characteristic  
§   Yellow  –  Green  Color  
•   Pigmented  Stone  
o   <10-­‐20%  of  cases  
o   Precipitation  of  UN/DECONJUGATED  bilirubin  with  CaCO3  creating  
CalciumBilirubinate  (deconjugating  of  bilirubin  happened  normally  in  
gallbladder…  just  really  slow)  
o   Characteristic  
§   Black  
§   Small  
§   Spiculated  
§   Brittle  
•   Brown  Stone  
o   Common  in  Ecoli  infection  /  Ascaris  lumbricoides  /  Liver  Fluke  
o   Ecoli  infection  change  conjugated  bilirubin  to  unconjugated  and  
precipitate  with  dead  cell  of  Ecoli  +  CaCO3  
o   Characteristic  
§   Brown  color  
3.   Risk  Factor  
•   Women  (>  men)  is  at  risk  because  Estrogen  increase  cholesterol  precipitation  
o   Thus  oral  contraceptive,  Estrogen  replacement  therapy,  Pregnant    
•   4  F’s  
o   Female  
o   Forty  (Obese)  
 o   Fat  
o   Fertile  
•   Rapid  weight  loss  also  increase  precipitation  due  to  decrease  of  lipid.  
•   Decrease  intake  of  fats  =  stasis  
•   Decrease  emptying  of  gallbladder  
o   Decrease  intake  of  fats  /  fasting  
o   Spinal  cord  injury  
 
4.   Clinical  
•   Cholelithiasis  /  Cholecystolithiasis  (No  Jaundice  )  
o   Stones  in  Gallbladder  
o   Usually  asymptomatic  until  it  blocks  the  neck  
§   Colic  Pain  at  epigastric  region  
§   Pain  after  eating  (±2  hours)  
o   Investigation  
§   USG  
§   CT/MRI  
o   Treatment  
§   If  asymptomatic  –  no  treatment  
§   Symptomatic  
•   Oral  bile  acid  
•   Cholecystectomy  
o   Complication  
§   Gallstone  ileus  (fistula  created  between  gallbladder  and  ileus.  
stone  got  through  and  stuck  in  ileum)  
§   Steatorrhea  
§   Choledocholithiasis  
§   Pancreatitis  
•   Choledocholithiasis  (Jaundice)  
o   Stone  in  Bide  Duct  
o   Clinical  
§   Symptomatic  
•   Jaundice  (highly  increase  in  Direct  Bilirubin  and  slight  
increase  in  Undirect  bilirubin  –post  hepatic  jaundice)  –
if  arrived  at  common  bile  duct  or  large  enough  to  
block  common  hepatic  duct  
•   Colic  RUQ  pain  radiate  to  right  scapula  and  shoulder  
•   Stool  Acholic  Stool  
o   Investigation  
§   ERCP  to  detect  and  also  remove  
§    
o   Treatment  
§   Analgesic  
§   Antibiotic  
§   ERCP  
§   Sphincterotomy  
o   Complication  
 §   Pancreatitis  
§   Steatorrhea  
 
Cholecystisis  
1.   Acute  
o   Due  to  Cholecystolithiasis  =  Stasis  of  gallbladder  
§    Mucosa  wall  of  gallbladder  secrete  mucus  and  cytokines  
•   Increase  in  pressure  and  Inflammation  
§   Bacterial  Growth  
•   EColi  (most  common)  
•   Enterococci  
•   Bacteroides  fragilis  
•   Clostridium  
o   Clinical  
§   Mid  epigastric  pain  and  if  later,  shift  to  right  upper  quadrant  radiate  
to  right  scapula  and  shoulder  
§   Nausea  +Vomiting  
§   Peritonitis  due  to  ecoli  =  Rebound  tenderness  around  RUQ  area  
§   Murphy  sign  +  
§   Neutrophilic  leukocytosis  
§   Fever  
§   Jaundice  in  mirrizi  syndrome  (<10%)  
o   Inflamed  gallbladder  
§   Recover  because  the  stone/blocking  falls  back  to  gallbladder  
§   Or  got  worse  
•   Due  to  increase  pressure  and  size  
•   Blocking  gallbladder  artery  =  ischemia  –  necrosis  –  rupture  –  
sepsis  
o   Diagnose  
§   USG  
•   Stone,  mucus  buildup,  wallthickness  
•   Cholescintigraphy  
§   Xray  
•   Radio  opaque  
•   Pneumonia  if  disseminated  
§   CT  
•   Perforation  
o   Treatment  
§   Conservative  
•   IV,  Analgesic,  Antibiotic,  Non  per  Oral  
§   Cholecystectomy  
2.   Chronic  
o   Constant  inflammation  because  of  stone  in  gallbladder  
§   Rockitansky  Aschoff  sinus  in  mucosa  (histology)  
§   Pain  in  RUQ  to  shoulder/scapula  
§   (Porcelain  gall  bladder)  Fibrosis  and  necrosis  and  calcification  
o   Treatment  
 §   Removal  (Cholecystectomy)  
 
Cholangitis  
1.   Etiology  
a.   Obstruction  
i.   Choledocholithiasis  
ii.   Stricture  
2.   Clinical  
a.   Charcod’s  Triad  
i.   Jaundice  
ii.   Fever  
iii.   Abdominal  Pain  
b.   Reynald’s  Pentad  (Shock)  
i.   Charchod  Triad  
ii.   +  Hypotension  
iii.   +  Altered  mental  State  
c.   Acholic  Stool  
3.   Investigation  
a.   ESG  
i.   Dilated  bile  duct  
b.   ERCP    
i.   To  see  the  block  and  remove  
c.   Lab  
i.   Leukocytosis  
d.   Pancrease  amylase  >1000  iu/ml  
e.   Bilirubin  (post  hepatic)  
4.   Treatment  
a.   IV  
b.   Analgesic  
c.   Antibiotic  
d.   Hemodynamic  monitoring  
e.   ERCP