1. GALLSTONES
By: Anika Khan
Role #1030

2. 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

3. 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

5. 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.

6. 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

7. 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.

8. 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

9. 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

10. In the GB: In the bile ducts: In the gut: Biliary colic
Acute and chronic cholecystitis
Empyema
Mucocoele
Carcinoma
In the bile ducts:
Obstructive jaundice
Pancreatitis
Cholangitis
In the gut:
Gallstone ileus

11. 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

12. 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: ?

13. diagnosis → denotes gallstones
► denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone

14. references http://www.medscape.com/viewarticle/781782_2
treatment#aw2aab6b6b3
conditions/gallstones/basics/tests-diagnosis/con