Gallstones and gallstone-related disease🎥
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Gallstones and gallstone-related disease
Introduction
Gallstones (cholelithiasis) are crystalline concretions, usually composed of cholesterol or pigment, that form within the gallbladder. While many individuals remain asymptomatic, gallstones can present with a range of clinical syndromes depending on their location and complications, including biliary colic, acute cholecystitis, and ascending cholangitis.
Peak Incidence
- Most common in women over the age of 40 (“female, fat, forty, fertile” is a classic risk mnemonic).
- Risk factors include female sex, age >40, obesity, pregnancy, rapid weight loss, and certain medications (e.g. oestrogens).
Pathophysiology
- Gallstones form when bile becomes supersaturated with cholesterol or bilirubin.
- Risk increases when bile becomes concentrated, stasis occurs, or mucin production increases.
- Obstruction of the cystic duct or common bile duct by gallstones leads to symptoms and complications:
- Cystic duct obstruction → biliary colic or cholecystitis
- Common bile duct obstruction → ascending cholangitis or obstructive jaundice
- Ampulla of Vater obstruction → pancreatitis
Symptoms
Biliary Colic
- Intermittent right upper quadrant (RUQ) pain, often postprandial (especially after fatty meals)
- Pain is colicky and may radiate to the back or right shoulder
- Nausea and vomiting may occur
- No fever; patient should appear systemically well
Acute Cholecystitis
- Constant, severe RUQ pain (not colicky)
- May radiate to the right shoulder or scapula
- Fever and systemic inflammation
- Nausea and vomiting
- Symptoms persist >6 hours
Ascending Cholangitis
- Charcot’s Triad: RUQ pain + fever + jaundice
- Reynold’s Pentad (severe disease): Charcot’s triad + hypotension + altered mental status
- May progress to sepsis or multiorgan failure if untreated
Signs
- RUQ tenderness
- Murphy’s sign positive in acute cholecystitis (pain on deep inspiration during RUQ palpation)
- Fever, jaundice
- Signs of systemic inflammatory response or sepsis in cholangitis
- Signs of chronic anaemia or weight loss in longstanding disease
Diagnosis
Biliary Colic
- Blood tests: Normal inflammatory markers and LFTs
- Ultrasound (first-line):
- Gallstones in gallbladder
- No wall thickening or pericholecystic fluid
- MRCP (if LFTs are abnormal):
- Assess for common bile duct (CBD) stones
Acute Cholecystitis
- Blood tests:
- ↑ WCC and CRP
- Mildly abnormal LFTs (if bile duct involved)
- Ultrasound:
- Gallstones
- Gallbladder wall thickening (>3 mm)
- Pericholecystic fluid
- MRCP: If ultrasound inconclusive or CBD stones suspected
- ERCP: Not routinely used unless CBD obstruction suspected
Ascending Cholangitis
- Blood tests:
- ↑ WCC and CRP
- ↑ ALP, GGT, bilirubin (cholestatic pattern)
- Ultrasound:
- Dilated bile ducts
- Gallstones in gallbladder or CBD
- MRCP: Confirms CBD stones or strictures
- ERCP: Diagnostic and therapeutic – stone extraction, stenting
Complications
Biliary Colic
- Progression to chronic cholecystitis
Acute Cholecystitis
- Gangrenous cholecystitis
- Gallbladder empyema
- Gallbladder perforation → peritonitis
- Cholecystoenteric fistula → gallstone ileus
- Chronic cholecystitis
Ascending Cholangitis
- Sepsis and septic shock
- Liver abscess
- Pericholecystic abscess
- Biliary strictures
General
- Obstructive jaundice – pale stools, dark urine, elevated bilirubin
- Acute pancreatitis – from blockage at the pancreatic duct junction
Management
Biliary Colic
- Pain relief:
- NSAIDs (e.g. diclofenac 75 mg IM) are first-line
- Dietary advice:
- Low-fat diet to reduce symptoms
- Definitive treatment:
- Elective laparoscopic cholecystectomy
Acute Cholecystitis
- Admission to hospital
- IV antibiotics: e.g. co-amoxiclav ± metronidazole
- Analgesia: paracetamol ± NSAIDs
- Surgery:
- Emergency laparoscopic cholecystectomy within 24–48 hours
- Percutaneous cholecystostomy if patient unfit for surgery
Ascending Cholangitis
-
Admission and sepsis management:
- IV fluids, antibiotics, and start Sepsis Six if indicated
- Escalate to critical care if haemodynamic instability
-
Biliary drainage:
- ERCP (first-line): for stone removal ± stenting
- Percutaneous transhepatic drainage: if ERCP fails or unavailable
- Surgical drainage: reserved for refractory or complicated cases
FAQ from our users
Why does increased oestrogen increase the risk of gallstones?
- Oestrogen can increase cholesterol levels in bile and also decrease the motility of the gallbladder which can lead to gallstone formation.
Why does biliary colic come in waves?
- This is because the gallbladder naturally contracts & relaxes to release bile. When it contracts against a lodged stone, this is when pain can be felt by the patient.
What is seen on abdominal US for biliary colic?
- Gallstones in the gallbladder or in the ducts
- Bile duct dilatation
- Cholecystitis may show thickening of the gallbladder wall / excess fluid
What are the types of gallstones?
- Cholesterol Stones (~80%)
- Formed from cholesterol supersaturation.
- Risk factors: obesity, high-fat diet, pregnancy, rapid weight loss, and metabolic syndrome.
- Pigment Stones (~20%)
- Formed from excess bilirubin in bile (associated with haemolysis, cirrhosis, and biliary infections).
- Can be black (associated with haemolysis) or brown (associated with biliary infection).
- Mixed Stones
- Combination of cholesterol, calcium, and pigment components.
What are the risk factors for developing gallstones
- The Four F’s:
- Fat (obesity and high body fat percentage increase the risk)
- Female (higher prevalence in women)
- Fertile (pregnancy increases the risk due to hormonal changes)
- Forty (more common in individuals over 40 years old)
- Additional risk factors include:
- Diabetes mellitus
- Crohn’s disease (due to impaired bile salt absorption in the terminal ileum)
- Dietary factors such as high triglycerides, refined carbohydrates, and low fiber intake
- Rapid weight loss
- Increased estrogen levels from hormone replacement therapy or combined oral contraceptive pills (COCP)
- Prolonged total parenteral nutrition (TPN) use
Common pitfalls in a clinical setting
Common pitfalls in a clinical setting
-
Do not forget to exclude differential diagnoses for other causes of abdominal pain including:
- cholecystitis
- peptic ulcer disease
- pancreatitis
- GORD
- acute hepatitis
- gastritis
- IBD / IBS
- tumours of the gallbladder, liver, stomach, gut & pancreas
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The condensed management is outlined in the notes but do not forget to include a more holistic management plan for your OSCEs. This should include pain relief. NICE guidance recommend diclofenac 75mg IM (unless contraindicated) for patients in severe pain.
-
Asymptomatic gallstones often do not require treatment & reassurance is often sufficient in such patients. That being said, referral might be made for patients with asymptomatic stones in the common bile duct. This is because there is a significant risk of developing serious complications such as cholangitis or pancreatitis.
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An easy way differentiate ascending cholangitis and other gallbladder pathologies in an exam
- No jaundice
- Biliary colic – pain
- Acute cholecystitis – pain and fever
- With jaundice
- Choledocholithiasis – pain
- Acute cholangitis – pain and fever
- No jaundice
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A summary between ascending cholangitis, cholecystitis, and biliary colic.
Ascending cholangitis Cholecystitis Biliary Colic Aetiology Obstruction of the biliary tree Obstruction of the gallbladder or cystic duct Biliary obstruction (typically from stones) Type of pain Severe continuous Severe continuous Colicky interment Jaundice Present may be present Absent Fever Present may be present Absent Murphy’s sign Negative Positive Negative -
Terms to be aware
- Biliary colic: Pain in the right upper quadrant (RUQ) caused by gallstones blocking the bile duct. This is the most common complication of gallstones.
- Cholecystitis: Inflammation of the gallbladder itself, usually occurring when a gallstone obstructs the cystic duct. This is the second most common complication of gallstones.
- Cholangitis: Inflammation of the bile duct, often caused by bacterial infection. It commonly presents with jaundice.
- Acute pancreatitis: Inflammation of the pancreas that can be triggered by gallstones blocking the pancreatic duct.
- Cholestasis: Blockage of bile flow.
- Cholelithiasis: The presence of gallstones in the gallbladder.
- Choledocholithiasis: The presence of gallstones in the bile duct.
- Gallbladder empyema: The accumulation of pus within the gallbladder.
- Cholecystectomy: Surgical removal of the gallbladder.
- Cholecystostomy: The insertion of a drain into the gallbladder.
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