• Cholelithiasis - presence of gallstones in gall clagger

  • 10-15% populaiton

  • 20% 30-75 in NZ

  • most asymptomatic

  • most sympomts caused by blockage of cystic duct by gallstone

    • migration of gallstone into cbd

  • blockage of common bile duct = may be accompanied by jaundice, pancreatitis or cholangitis

  • 70% cholesterol stones

    • > 50% formed by cholesterol

  • Black pigment stones = calcium bilirubinate

    • haemolytic disorders

    • increase bilirubin load

    • occasoinally cirrhosis

  • diagnosies by abdominal uss

Riskfactors

  • increase age

  • increase bmi

    • increase production of cholesterol by liver

  • female

    • oestrogen increase biliary secretion of cholesterol and progesterone decrease bile acid secretion by increase gallbladder stasis

  • pregnancy

  • medicines - ocp, fibrates

  • fhx

    • 1st deg. relative - 4.5x more likely

  • rapid weight loss

  • haemolytic disorders

  • increased in crohn’s disease

    • bile acid reabsorption in diseased terminal ileum is reduced

diagnosis

symptoms

  • bilary colic = steady pain compared to series of colicky waves

  • pain originates in RUQ/epigastrum

  • can radiate subscapular region

  • pain ypically last > 30min with an upper limit of 6hrs

    • unaffected by movement

    • body posiition

    • defecation

  • often nauseated and may vomit

  • may occur following a meal

    • or at night

  • recurrence common

  • atypcial

    • chest pain

    • belching

    • rapid satiety

    • dyspepsia

    • non-specific abdominal pain

Choledocholithiasis — gall stone in CBD

indistinguishable from bilary colic

accompanied by obstructive jaundice

cholangitis

acute pancreatitis

bactraemia increased

cholecystitis

  • severe and ongoing pain and rebound tenderness on exam

    • acute cholecysitis

      • + murphy’s

        • negative sign deson’t exclude cholecystitis

          • particularly in older patients

  • Ascending cholangitis

    • Charcot’s triad

      • jandice

      • fever

      • RUQ pain

  • Mirizzi syndrome

    • long-term gallstone disaese

    • imaging

    • presentation varies greatly

Investigation

  • FBC

  • LFT

  • Cr

  • CRP

  • serum amylase

  • urine dipstick

ultrasound = gold-standard diagnostic test

prompt (within 5 days)

jaundice and abnormal LFT

significant , persistent, recurren upper quadrant pain

can detect \~95% gallstones + complications

routine uss (within 4 weeks)

Red falgs for acute referral

  • Bilary colic cannot be effectively controlled with analgesia

  • obstructive jaundice

  • suspected acute cholecystiis

  • cholangitis

  • acute pancreatiis

pregnancy

  • physiological changes

    • increase gallbladders tasis

    • increase bile production

    • increase cholesterol

    • decrease bile acid

    • later in preganccy consider HELLP

Management

Lifestyle

  • fatty food

  • nuts and low saturated fat = reduced risk of gallstone formation

  • coffee may be protective

-

Analgesia

  • NSAIDs

    • preferred class of analgesia

    • Diclofenac injectable IM - deep into upper outer quadrant of gluteal muscle

      • repeated once

      • good speed on onset and IM and avialbility

    • better compared to anti-spasmodic medicines

    • equally effective as opioids - mainly pethidine

  • Codeine//paracetamol

    • may be effective/superior to NSAIds

  • Opioids

    • alternative for severe pain

  • antiemetics

  • Antispasmotics

    • produce effective analgesia in some with biliary colic

    • hyosciene butylbromide

      • 20mg qds

    • also 20mg/mL repeated after 30min

      • max 100mg/day

Surgical

  • refer for surgical intervention

  • 1-3 days

  • conversion to open \<5%

Complciations/consequences

  • gallstones = risk for gallbladder cancer