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.