Present in 10 –
20% of the population in the West
More common in young
women than young men, difference decreases with age
Rare in Africa
Composed of
cholesterol and bile pigments – 80% 0f stones
Pure cholesterol
stones are often solitary and less common
Bile pigment and
calcium stone occur in people with increased haemolysis
Cholesterol based
stones form when there is an excess of cholesterol over bile salts in the bile
Cholesterol crystals
form and acts as an attraction for more precipitation
Essentially unknown,
probably related to metabolic factors
Age and sex Multiparity Obesity
High animal fat diet Diabetes Oral
contraception-
Clinical
picture
80% of gallstones
remain in the gall bladder and are asymptomatic
18% have symptoms
over a 15 year period
Stone may impact in
the neck of the gallbladder or in the cystic bile duct ---------- biliary pain,
Cholecystitis
Stasis may lead to bacterial
infection ------- cholangitis
Pain in epigastrium
and right hypocondrium
Stone in the common bile duct
Biliary
obstruction --------- severe
biliary pain, cholestatic jaundice
Classical triad -
abdominal pain, jaundice, fever
Vomiting
Pain for a few hours,
returning after days, weeks or months
Leucocytosis Blood
culture may grow gut organisms
Ultrasound Endoscopic
retrograde cholangiopancreatography
Complications
of gallstones
Pancreatitis Fistula
formation Gallstone
ileus Carcinoma
of the gall bladder
Management
Cholecystectomy -
laproscopic if possible
Some cholesterol only
stones may be dissolved with medication
Lithotripsy
Stones in the CBD can
be removed by endoscopic sphincterotomy, if necessary followed by removal, or surgically
Inflammatory
conditions
Acute
cholecystitis
Pathophysiology
90% of cases caused
by gallstone obstruction in neck or cystic areas ------------ distension and
inflammation
Usually infected with
gut organisms within 24 hours
Condition varies but
is usually severe
Gall bladder wall
involvement -------- localised peritonitis and acute pain
Empyema may occur
Acute gangrenous
cholecystitis will lead to generalised peritonitis
Clinical features
Pain may radiate
through to back and shoulder
Severe continuous
pain increasing in intensity over 24 hours
Possible nausea
vomiting
Possible mild
jaundice from inflammatory obstruction
Fever Shallow
respirations Guarding
and rebound Leucocytosis
Features seen on
ultrasound
Management
Rest NBM IVIs Antibiotics Analgesia
Oral fluids when
tolerated Cholecystectomy
after a few days
Acute
cholangitis
Bile duct abnormality
leads to bacterial infection
Ductal pathology
includes stones, strictures
Fever, upper
abdominal pain, jaundice
Possible septicaemia
Treat with iv
antibiotics
Primary
sclerosing cholangitis
Inflammation and
sclerosing of the bile ducts
Might be
immunological No
specific treatment
Malignant
conditions
Primary carcinoma of the gall bladder
1 % of cancers Mostly
over 70 years of age
More common in
females Possible
relationship with gallstones
Jaundice, pain,
possible palpable mass
Cancers of the bile
ducts or ampula occasionally present