Patients regularly present under the surgical take with gall stone disease. The aim of this article is to help you understand when you're looking after these patients what you're monitoring for, what investigations are necessary, what their likely management will be & the discharge information you can provide them.

92% of patients with gall stone disease present with biliary colic or cholecystitis rather than cholangitis or other rarer presentations of gall stone disease. Note that about 15% of asymptomatic patients have gall stones. Thus identifying gall stones does not mean that's the cause of a patient's symptoms. Only up to 25% of those with gall stones will ever develop symptoms.

Definitions: (explained again below)
  • Cholelithiasis – formation of gallstones in the gallbladder
  • Choledocholithiasis – presence of gallstones within the CBD
  • Cholecystitis – inflammation of the GB
  • Cholangitis – inflammation of the bile ducts
  • Cholestasis – failure of normal amounts of bile to reach intestine
Clinical presentation:
Anyone presenting with RUQ abdo pain should have gallstone related biliary disease in their differentials. Other features may include fevers, jaundice and being systemically unwell.

History:
  • SOCRATES for abdo pain (intermittent/ episodic RUQ pain, radiating to back, onset after eating (especially fatty foods))
  • Any systemic upset?
  • Any jaundice? Stool or urine colour change?
  • Any weight loss? (Sudden weight loss is a risk factor)
  • Known gallstones or high cholesterol?
  • Other risk factors: diabetes, previous ileal disease or surgery
  • Alcohol/ dietary hx
  • Drug hx
  • FHx
  • PMHx
  • PSHx - note that patients can form stones in the CBD even when they've had a cholecystectomy. Specifically ask if they've had episodes like this before. 
  • Analgesia
Examination:
  • End of the bed jaundice? High BMI? Looks unwell? Looks in pain?
  • ABCDE
  • ?Murphy sign i.e. local peritonism (palpate subcostally in the RUQ region and then ask the patient to breathe in & look for worsening pain/wincing. Repeat for the LUQ and confirm this is isn't just as deep breathing is painful)
Investigations:
  • Bloods: FBC/ U&E/ LFTs/ CRP/ amylase (coagulation if patient for ERCP)
  • Blood cultures
  • Urinalysis - ?bilirubin/ urobilinogen
Imaging:
  • Abdominal ultrasound - evidence of stones/ dilated CBD or intrahepatic ducts. Note the patient ideally needs to be fasted for this.
  • MRCP – if evidence of stones obstructing the CBD with very deranged LFTs may go straight to ERCP. However if high clinical suspicion (deranged LFTs/jaundice) & if no stones seen on ultrasound scan consider discussing whether MRCP is indicated with your seniors (take note of contraindications to MRI and assess patient prior)
Management
  • Ensure patients have adequate analgesia & antibiotics if they are indicated (see below)
  • Don't forget VTE prophylaxis
  • Observe for signs of peritonism - the gall bladder can perforate
Understanding gall stone disease

From webmd.com

Biliary colic
  • The gall stone transiently blocks the cystic duct. Usually for a few hours but it can be anywhere from 15 minutes to up to 24h
  • This often occurs after eating (post-prandial) when the gall bladder contracts
  • Thus the usually asymptomatic stones, present with a continuous RUQ pain but with a normal examination & a systemically well patient as there's no infection
  • Discharge advice: low fat diet, analgesia, exercise & obesity management, if recurrent can be followed up in outpatients for consideration of cholecystectomy
Cholecystitis
  • The cystic duct is more properly obstructed with inflammation of the gall bladder
  • Due to this inflammation & infection, the patient is systemically unwell with fever and malaise
  • Examination reveals constant RUQ pain, Murphy's sign but no jaundice (as the common bile duct remains unobstructed)
  • Observe for sepsis (and treat accordingly), deranged LFTs/jaundice for cholangitis (although note co-amoxiclav can derange LFTs in an obstructive pattern) & signs of peritonism. 
  • The obstructed gall bladder may accumulate fluid (mucocele) which could be purulent (gall bladder empyema). These may require surgery. Generally up to 20% might need an emergency inpatient cholecystectomy. 
  • Manage with supportive care, antibiotics & analgesia
  • Discharge advice as above except they will be usually considered for cholecystectomy. 
Ascending cholangitis *obstructive jaundice until proven otherwise*
  • The stone has travelled further to where the cystic duct joins the hepatic ducts to form the common bile duct. Rarely the stone might be in the cystic duct but directly compressing the hepatic ducts resulting in the same clinical picture (called Mirizzi's syndrome)
  • This results in much more serious infection with jaundice (Charcot's triad of RUQ pain, fever & jaundice)
  • Observe for sepsis & signs of peritonism as above
  • Hopefully with IV antibiotics & supportive care the inflammation and obstruction will resolve. If it doesn't they may need an ERCP. MRCP may be used to confirm the issue & guide the performing doctor where the stone is.
  • Discharge advice as above, including that they will be referred for cholecystectomy which usually the surgeon does electively once the inflammation has settled & it is safer
Gall Stone Pancreatitis
  • The stone could also obstruct the pancreatic duct & cause pancreatitis
Gall Stone Ileus
  • The stone could also descend through a fistula directly into the bowel & cause an ileus. This is very rare but is associated with higher mortality.
Further Information for Interest
Pathophysiology: Two main type of stones (often mixed):

Cholesterol (90%)
  • Due to cholesterol excess in bile
  • Risk factors: FHx, obesity, sudden weight loss, age, oestrogen
  • (“5 F’S” – female, fertile, fat, fair and forty)
Pigmented gallstone
  • Due to bilirubin excess in bile with two subtypes:
    • Black – increased haemolysis e.g. sickle cell/ spherocytosis
    • Brown (ductal) – form in bile ducts (not GB) due to stasis/ infection
Further Reading
Written by Rachael Boardley
Edits by Akash Doshi CT2