Gallstones

Gallstones are usually regarded as surgical problems (Problems for which an operation is the likely cure) however they often present to gastroenterologist because many of the symptoms overlap with other gastrointestinal disease. Within the normal population approximately one third of the population will have gallstones residing within their gallbladder but most people are entirely asymptomatic and the stones require no further action unless they cause symptoms (even laparoscopic surgery is not without risk). For those who develop symptoms these may take several guises.

 

Cholecystitis

This is a descriptive term for inflammation in the gallbladder which commonly arises as a result of the outlet of the gallbladder being obstructed, often by a gallstone. The body of the gallbladder becomes inflamed causing thickening of the gallbladder wall. Patients usually present with right upper quadrant pain, often with associated nausea, belching and indigestion, but pain can arise in any part of the upper abdomen. The diagnosis is usually confirmed on examination by marked tenderness just below the ribs on the middle of the right side. (Murphy’s sign). Investigation of choice is usually ultrasound and liver function test. Ultrasound usually reveals a thickened gallbladder wall with the gallbladder often containing multiple stones. Usually the ultrasonographer will try to identify and examine the common bile duct, which leads down from the gallbladder, via the cystic duct into the small bowel. If the duct is dilated (wider calibre than normal) or the liver function tests are abnormal this may be suggestive of choledocholithiasis (a stone stuck in the bile duct). In the context of dilated common bile duct or abnormal liver tests an MRCP may be appropriate. If the diagnosis remains in doubt then an EUS may be appropriate.

In those who are fit for surgery cholecystectomy (surgical removal of the gallblader), following initiation of antibiotic therapy is usually the treatment of choice. NICE guidance suggests in people with acute cholecystitis, laparoscopic cholecystectomy within a week should be undertaken in those where such surgery is appropriate.