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Understanding Biliary Colic and Cholecystitis

May 17, 2025

Lecture Notes: Biliary Colic and Cholecystitis

Introduction

  • Gallstone disease affects 10-14% in Western populations, mainly asymptomatic.
  • 1-4% develop symptoms due to gallstones.
  • Spectrum of disease: biliary colic to acute pancreatitis depending on the biliary system region involved.

Pathophysiology

  • Bile composed of cholesterol, phospholipids, and bile pigments stored in the gallbladder.
  • Gallstones form due to bile supersaturation:
    • Cholesterol stones: Linked to poor diet, obesity.
    • Pigment stones: Common in haemolytic anaemia.
    • Mixed stones: Cholesterol and bile pigments.

Risk Factors

  • "5 Fs": Fat, Female, Fertile, Forty, Family history.
  • Others: Pregnancy, oral contraceptives, haemolytic anaemia, malabsorption (Crohns, ileal resection).

Clinical Features

  • Symptomatic presentation: >50% biliary colic, 35% acute cholecystitis.

Biliary Colic

  • Occurs when gallbladder neck impacted by gallstone; no inflammatory response.
  • Symptoms: Sudden, dull, colicky pain in right upper quadrant (RUQ), possibly radiating, often post-fatty meals.

Acute Cholecystitis

  • Constant RUQ/epigastrium pain with inflammation signs (fever, lethargy).
  • Tenderness in RUQ, positive Murphy's sign.

Murphy's Sign

  • Pain halts inspiration when RUQ is pressed and patient inspires, indicating inflamed gallbladder.

Differential Diagnosis

  • Consider gastro-oesophageal reflux, peptic ulcer, acute pancreatitis, inflammatory bowel disease.

Investigations

Laboratory Tests

  • FBC, CRP (inflammation), LFTs (ALP raised), Amylase (pancreatitis check), Urinalysis with pregnancy test.

Imaging

  • Trans-abdominal ultrasound: First line for gallstones, checks gallstones, wall thickness, bile duct dilation.
  • MRCP: Gold standard if US inconclusive, shows biliary tree defects.

Management

Biliary Colic

  • Prescribe analgesia (paracetamol/NSAIDs/opioids).
  • Lifestyle changes: low-fat diet, weight loss, exercise.
  • Elective laparoscopic cholecystectomy within 6 weeks of first presentation.

Acute Cholecystitis

  • Start IV antibiotics (e.g., co-amoxiclav), analgesia, antiemetics.
  • Laparoscopic cholecystectomy within 72 hours recommended.
  • Percutaneous cholecystostomy if unfit for surgery.

Complications

Mirizzi Syndrome

  • Stone in Hartmann's pouch compresses common hepatic duct causing obstructive jaundice.
  • Confirm with MRCP, manage with laparoscopic cholecystectomy.

Gallbladder Empyema

  • Gallbladder filled with pus, presents similar to acute cholecystitis.
  • Diagnosed with US/CT, treated with cholecystectomy or cholecystostomy if unsuitable for surgery.

Chronic Cholecystitis

  • Recurrent cholecystitis leading to persistent gallbladder inflammation.
  • Diagnosed via CT, managed with elective cholecystectomy.

Bouveret's Syndrome and Gallstone Ileus

  • Gallbladder inflammation causes fistula with bowel, stones enter bowel causing obstruction.
  • Bouveret's: Stone in duodenum (gastric outlet obstruction).
  • Gallstone Ileus: Stone in terminal ileum (bowel obstruction).

Key Points

  • Gallstones are common, often asymptomatic.
  • Risk factors: High-fat diet, female gender, malabsorption, oral contraceptive use.
  • Diagnosed mainly by US scan.
  • Definitive treatment: Laparoscopic cholecystectomy.