Gall stones
Physiology
In the fasting state, only 50–60% of bile goes to the gall bladder.
The rest trickles through to the intestine regardless.
Gallbladder contraction and relaxation of the sphincter of Oddi
is stimulated by cholecytokinin (CCK). The biliary tree is a low pressure system,
and the flow of bile stops at 20 cm H2O.
Biliary colic
Symptoms
Severe colicky RUQ pain after fatty meals. Vomiting.
Signs
None.
Investigations
US shows gallstones in the gallbladder.
ΔΔx.
Ureteric colic, gallbladder dyskinesia.
Treatment
Elective cholecystectomy.
Acute cholecystitis
Symptoms
Fever, RUQ pain.
Signs
RUQ tenderness, mass.
Investigations
FBC(↑WBC), U&E(hepatorenal syndrome), amylase, blood cultures.
erect CXR, supine AXR to exclude perforation.
US gall bladder: thickened wall, stones, pericholecystic fluid.
Treatment
Cefuroxime + metronidazole (most often E. coli). Diamorphine.
Cholecystectomy.
Chronic cholecystitis
Symptoms
Abdominal discomfort, distension, flatulence, fat intolerance.
Fever not always present.
Ascending cholangitis
Features
Charcot's triad:
Reynold's pentad:
- Charcot's triad
- Hypotension
- Altered mental state
Treatment
Cefuroxime + metronidazole. Biliary drainage.