GALLSTONES - Clinical features, Differential diagnosis, Prophylaxis

Gallstones are present in 10-20% of the population. They are most common in women, and the prevalence increases with age.

Pathophysiology

Gallstones are of two types:

■ Cholesterol gallstones account for 80% of all gallstones in the Western world. Cholesterol is held in solution by the detergent action of bile salts and phospholipids, with which it forms micelles and vesicles. Cholesterol gallstones only form in bile which has an excess of cholesterol, either because there is a relative deficiency of bile salts and phospholipids or

a relative excess of cholesterol (supersaturated or lithogenic bile). The formation of cholesterol crystals and gallstones in lithogenic bile is promoted by factors that favour nucleation, such as mucus and calcium. Gallstone formation is further promoted by reduced gall bladder motility and stasis. The mechanism of cholesterol gallstone formation in patients with risk factors (Table 4.12) is frequently multifactorial (cholesterol supersaturation, nucleation factors and reduced gallbladder motility).

■ Pigment stones consist of bilirubin polymers and calcium bilirubinate. They are seen in patients with chronic haemolysis, e.g. hereditary spherocytosis and sickle cell disease, in which bilirubin production is increased, and also in cirrhosis. Pigment stones may also form in the bile ducts after cholecystectomy and with duct strictures.

Clinical presentation

Most gallstones never cause symptoms, and cholecystectomy is not indicated in asymptomatic cases. The complications are summarized in Fig. 4.8.

Biliary pain

Biliary pain (colic) is the term used for the pain associated with the temporary obstruction of the cystic or CBD by a stone.

Clinical features

There are recurrent episodes of severe constant pain in the upper abdomen, which subsides after several hours. The pain may radiate to the right shoulder and right subscapular region and is often associated with vomiting. Examina-tion is usually normal.

Table 4.12 Risk factors for cholesterol gallstones

Increasing age
Sex (F > M)
Family history
Multiparity
Obesity ± metabolic syndrome
Rapid weight loss
Diet (e.g. high in animal fat/low fibre)
Ileal disease or resection (leading to bile salt loss)
Diabetes mellitus
Acromegaly treated with octreotide
Liver cirrhosis

The complications of gallstones

Fig. 4.8 The complications of gallstones.

Investigations

The diagnosis is usually made on the basis of a typical history and an US showing gallstones. Increases of serum alkaline phosphatase and bilirubin during an attack support the diagnosis of biliary pain. The absence of inflam-matory features (fever, white cell count and local peritonism) differentiates this from acute cholecystitis.

Management

The treatment is analgesia and elective cholecystectomy. Abnormal liver biochemistry or a dilated CBD on ultrasonography is an indication for pre-operative MRCP. CBD stones identified on imaging are removed at ERCP or sometimes at the same time as cholecystectomy.

Acute cholecystitis

Acute cholecystitis follows the impaction of a stone in the cystic duct or neck of the gall bladder. Very occasionally acute cholecystitis may occur without stones (acalculous cholecystitis).

Clinical features

The initial clinical features are similar to those of biliary colic. However, over a number of hours there is progression to severe pain localized in the right upper quadrant, which is associated with a fever and tenderness and muscle guarding on examination. The tenderness is worse on inspiration (Murphy's sign). Complications include an empyema (pus) and perforation with perito-nitis. The diagnosis of acute cholecystitis is usually straightforward. The differential diagnosis is from other causes of severe right upper quadrant pain (p. 68).

Investigations

■ White cell count shows leucocytosis.

■ Serum liver biochemistry may be mildly abnormal.

■ Abdominal US shows gallstones and a distended gall bladder with a thickened wall. There is focal tenderness directly over the visualized gall bladder (sonographic Murphy's sign).

Management

The initial treatment is conservative, with nil by mouth, intravenous fluids, pain relief and intravenous antibiotics, e.g. cefotaxime. Cholecystectomy is usually performed within 48 hours of the acute attack, and always if compli-cations (see above) develop.

Chronic cholecystitis

Chronic inflammation of the gall bladder is often found in association with gallstones. On US examination this may appear as a small shrunken gall bladder. There is no evidence that this produces any symptoms, and chole-cystectomy is not indicated. Chronic right hypochondrial pain and fatty food intolerance are likely to be functional in origin and gallstones an incidental finding.

Acute cholangitis

This is an infection of the biliary tree and most often occurs secondary to CBD obstruction by gallstones (choledocholithiasis). Other causes are benign biliary strictures following biliary surgery or associated with chronic pancrea-titis, PSC, HIV cholangiopathy (p. 52) and in patients with biliary stents. Bile duct obstruction due to cancer of the head of pancreas or bile duct (cho-langiocarcinoma) can also cause cholangitis and this is more likely after ERCP. In the Far East, parts of eastern Europe and the Mediterranean, biliary parasites can cause blockage and cholangitis.

Clinical features

The classic description of cholangitis with fever, jaundice and right upper quadrant pain (Charcot's triad) is not always present, although most patients have fever often with rigors. Jaundice is cholestatic in type, and therefore the urine is dark, the stools pale and the skin may itch. Elderly patients may present with non-specific symptoms such as confusion and malaise.

Investigations

■ White cell count shows leucocytosis.

■ Blood cultures are positive (E. coli, Enterococcus. faecalis, sometimes anaerobes) in about 30% of patients.

■ Liver biochemistry shows a cholestatic picture with a raised serum bilirubin and alkaline phosphatase.

■ US shows a dilated CBD and may show the cause of the obstruction.

■ MRCP can further assess the site and cause of obstruction.

■ ERCP is the definitive investigation and will also allow biliary drainage (see below). It will show the site of obstruction and the cause, and bile can be sampled for culture and cytology (if a malignant cause is suspected).

Management

Treatment of acute cholangitis includes resuscitation and volume replace-ment in shocked patients, pain relief, treatment of infection with appropriate intravenous antibiotics and relief of obstruction by biliary drainage. Bacterial infection may be polymicrobial and a suitable antibiotic regimen is a third-generation cephalosporin, e.g. cefotaxime (ciprofloxacin if allergic), plus metronidazole. An alternative regimen is amoxicillin, gentamicin (with appro-priate monitoring) and metronidazole. In endemic areas primary parasite infection must also be treated.

Biliary drainage and/or clearance is usually achieved at ERCP with or without sphincterotomy. The urgency of this procedure depends on the clini-cal condition of the patient and the initial response to antibiotics. Stones can be removed from the CBD, and a stent can be placed in the biliary tree if stones cannot be removed or to relieve obstruction in patients with cancer of the head of pancreas or CBD. Antibiotics are continued after biliary drain-age until symptom resolution, usually 7-10 days.

Common bile duct stones (choledocholithiasis)

CBD stones may also be asymptomatic with no features of cholangitis and present with abnormal liver biochemistry, usually with a cholestatic picture. US will usually show gallbladder stones and may show the obstructed CBD containing a stone. MRCP is more sensitive than transabdominal US and is sometimes performed if there is a high index of suspicion and the latter is negative. An alternative technique for imaging the biliary system is endo-scopic US.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

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Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

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Dermatology

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