Surgical Emergencies
Question 180 of 300
A 39 year old woman presents to the Emergency Department with a 6 hour history of right upper quadrant pain and vomiting. You suspect biliary colic. Assuming the patient has gallstones, what is the most likely composition of the stones?
Answer:
Gallstones can be classified by the dominant constituent that precipitates:- Cholesterol stones — by far the most common in western countries (approximately 90%).
- Pigmented stones — dark coloured stones made up of bilirubin and calcium salts.
- Mixed stones — a combination of cholesterol and pigment stones.
Gallstone Disease
Surgical Emergencies
Last Updated: 14th April 2023
Pathophysiology
A gallstone (cholelithiasis) is a solid deposit that forms within the gallbladder. Gallstones occur when there is a problem with the chemical composition of bile, which results in precipitation of one or more of the constituents. The reason the chemical constituents of bile may change to favour stone formation is often unclear.
Gallstones can be classified by the dominant constituent that precipitates:
- Cholesterol stones — by far the most common in western countries (approximately 90%).
- Pigmented stones — dark coloured stones made up of bilirubin and calcium salts.
- Mixed stones — a combination of cholesterol and pigment stones.
Risk factors
Risk factors for developing gallstones include:
- Crohn's disease.
- Diabetes mellitus.
- Diet — diets higher in triglycerides and refined carbohydrates and low in fibre are associated with gallstones.
- Female gender — women have 2–3 times higher incidence of gallstones compared to men.
- Genetic and ethnic factors.
- Increasing age — incidence rises noticeably in people aged over 40 years, and is 4–10 times more likely in older people, peaking at 70–79 years.
- Smoking.
- Non-alcoholic fatty liver disease.
- Obesity — people with a Body Mass Index (BMI) over 30 are at greater risk of gallstone formation.
- Prolonged fasting/weight loss — this causes gallbladder hypomotility and increases cholesterol excretion in bile.
- Weight loss exceeding 1.5 kg a week — for example, people who have had bariatric surgery are at increased risk due to cholesterol supersaturation of bile from enhanced cholesterol mobilisation accompanied by decreased bile acid secretion.
- Use of hormone replacement therapy (HRT) or oral contraceptives.
- Medication:
- Somatostatin analogue octreotide impairs gallbladder and small intestinal motility.
- Glucagon-like peptide-1 analogues are associated with an increased risk of bile duct and gallbladder disease.
- Ceftriaxone has been associated with pigment stone development due to precipitation in bile.
Complications
Complications of gallstones include:
- Biliary colic (this is pain caused by the gallbladder, cystic duct, or common bile duct contracting around a gallstone)
- Acute cholecystitis (this occurs when obstruction of the cystic duct leads to gallbladder inflammation), and may lead to:
- Necrosis of the gallbladder wall (gangrenous cholecystitis).
- Perforation of the gallbladder.
- Biliary peritonitis.
- Pericholecystic abscess.
- Fistula (between the gallbladder and duodenum).
- Jaundice (due to inflammation of adjoining biliary ducts — Mirizzi's syndrome).
- Acute pancreatitis (this occurs when a stone that has migrated along the common bile duct becomes stuck in the biliopancreatic duct causing pancreatic outflow obstruction)
- Obstructive jaundice (this occurs a partially or completely blocked common bile duct causes an accumulation of bile pigments in the bloodstream)
- Uncommon complications:
- Acute cholangitis (this occurs when there is complete obstruction of the bile duct resulting in cholestasis and infected bile duct)
- Fistula formation (if a gallstone erodes through the gallbladder a fistula can develop causing duodenal obstruction (Bouveret's syndrome). Erosion of a stone into the common bile duct produces a biliary fistula (a form of Mirizzi syndrome), and if it occurs in the ileum it is known as gallstone ileus.)
- Biliary peritonitis
- Gallbladder mucocele
- Gallbladder cancer
Clinical features
Suspect gallstone disease in people who present with the classical symptoms and signs of symptomatic gallstone disease, or complications of gallstone disease.
- Biliary colic
- This is the most common presentation.
- Steady non-paroxysmal biliary pain occurs in the epigastrium or right upper quadrant and typically lasts for more than 30 minutes, but less than eight hours.
- It is often severe, and may be associated with nausea and vomiting, but is not associated with fever, or abdominal tenderness.
- Acute cholecystitis
- This is the second most common presentation.
- Suspect acute cholecystitis when someone presents with:
- A history of sudden-onset, constant, severe pain in the upper right quadrant, lasting several hours.
- Anorexia, nausea, or vomiting.
- Fever.
- Tenderness in the upper right quadrant, with or without Murphy's sign on examination (inspiration is inhibited by pain on palpitation when the examiner's hand is positioned along the costal margin).
- Referred pain in the shoulder or interscapular region.
- A history of gallstones (cholelithiasis).
- Look for signs which may indicate a complication:
- Right upper quadrant palpable mass (distended gallbladder or an inflammatory mass around the inflamed gallbladder).
- Fever — persistent fever and pain may suggest complications such as abscess or perforation.
- Jaundice — may be due to biliary tract inflammation and oedema, pressure from a distended gallbladder, a stone in the common bile duct or impacted in the gallbladder neck (Mirizzi syndrome).
- More severe localised or generalised tenderness (may be associated with abscess formation or gallbladder perforation).
- Obstructive jaundice
- Yellowish discolouration of the skin, dark urine and pale stools.
- Cholangitis
- Typical features, referred to as Charcot's triad, are diagnostic: fever (often with rigors), jaundice, and right upper quadrant abdominal pain.
- Gallstone pancreatitis
- Constant epigastric pain radiating through to the back, and profuse vomiting.
Typical differentiating features between biliary colic, cholecystitis, and cholangitis
| Biliary colic | Acute cholecystitis | Ascending cholangitis | |
|---|---|---|---|
| RUQ pain | RUQ pain typically lasting < 8 hours, Murphy's sign negative | Persistent RUQ pain and tenderness, Murphy's sign positive | Persistent RUQ pain and tenderness, Murphy's sign negative |
| Fever | No | Yes | Yes |
| Jaundice | No | No | Yes |
Diagnostic tests
- If gallstone disease is suspected, offer:
- An abdominal ultrasound examination — this may confirm the presence of one or more gallstones. The absence of stones on ultrasound scan does not exclude their existence.
- Liver function tests (LFTs) — gallstones in the common bile duct may result in abnormal LFTs.
- Consider referral for further investigation if results are normal but clinical suspicion remains high. This may include:
- Magnetic resonance cholangiopancreatography (MRCP), if ultrasound has not detected common bile duct stones, but the bile duct is dilated and/or liver function test results are abnormal.
- Endoscopic ultrasound (EUS) if MRCP does not allow a diagnosis to be made.
Management
- Arrange emergency admission for people who are systemically unwell with a suspected complication of gallstone disease, such as acute cholecystitis, cholangitis, or pancreatitis for:
- Confirmation of the diagnosis (including abdominal ultrasound, and blood tests such as a white blood cell count, C-reactive protein, and serum amylase).
- Monitoring (for example blood pressure, pulse, and urinary output).
- Treatment (may include intravenous fluids, antibiotics, and analgesia).
- Surgical assessment for cholecystectomy.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
