Gallstones is where we’re at. There
might be a genetic predisposition.
If you see the letter F or
is your patient a woman, a female, F?
Is she in her reproductive age, fertile?
Is she pregnant? Is she fat?
Female, forty, fat, fertile, FFFF.
The type of gallstone that you’re thinking,
when the F criteria have been met,
cholesterol, the most common.
Now, with all that said,
be careful though, okay?
You want to take a look
at the history of your patient.
If there’s a history in which there’s
bilirubin, let’s say for example,
sickle cell disease, how much bilirubin
is being released?
Whew, a lot, right?
And if it’s bilirubin that
giving rise to a stone in the gallbladder,
why would you call that a
cholesterol stone? Do you see
what I’m saying?
So percentage-wise, sure, as long
as you meet the criteria, but be careful.
Pay attention to history.
Risk factors; octreotide, ceftriaxone,
OCP, prolonged TPN, and ileal disease
causing bile acid malabsorption.
For example, remember where
intrahepatic circulation takes place?
In the terminal ileum.
If there are indications for, perhaps,
for removing parts of terminal ileum,
there’s every possibility that
results in bile acid malabsorption.
Therefore, increases of the risk
of gallstones cholesterol type.
Two types, the type we
just talked about,
cholesterol -- FFFF, female,
forty, fat, fertile.
Pigment, I gave an example,
Sickle cell disease,
increased extravascular hemolysis.
You have unconjugated bilirubin,
and the bilirubin may also accumulate
within the gallbladder.
With the gallstone, what’s the
kind of pain
that the patient's going to feel?
What kind of meal? “Hey, doc. I just had a
"After a cheeseburger, how
did you feel?”
“Whoa, a pain. Shooting right here,
right upper quadrant."
On a scale of one to ten, with ten
being the worst pain that
the patient has experienced, the
patient feels pain at eight or nine.
Pretty sharp, isn’t it?
Biliary colic is what this
will be referred to as.
Topic: gallstone, presentation
that you’re looking at.
Every time there’s a
here comes my CCK from my Islet cell.
Pay attention to that.
But because of the obstruction,
the patient is going to have
right upper quadrant pain.
I told you it was a story.
So we ended up developing a stone.
The stone was in the gallbladder.
Every time there’s contraction,
the bile cannot come out.
Now the stone is making its way
to the head of the gallbladder.
Are you picturing it?
Picture that for me.
There’s my stone. And maybe it’s
in the cystic duct right there,
Every time there’s contraction,
contraction, contraction, contraction,
the stone gets in the way,
“Ouch, ouch, ouch,”
sharp pain, right upper quadrant.
Now, over repeated bouts of
how do you think the wall of the
gallbladder is then going to respond?
Inflammation. It has to.
This is called acute cholecystitis.
So move from biliary colic
in the previous discussion,
with pain, and the gallbladder,
it’s going to respond, and it’s
There will be right upper quadrant
pain with fever, nausea, and vomiting.
That’s a lot of pain.
Think about where you are.
Stone, gallbladder, cystic duct.
Of course, it’s obstructive jaundice.
A rare condition known as
Mirizzi's syndrome in which you
have adjacent structures such
as the common bile duct
which is also being affected.
Acute cholecystitis, acalculous type,
meaning to say you might not
even have a stone, but yet still
results in cholecystitis.
Critically ill patient, unfortunately,
there could be higher mortality
in terms of what may happen.
over a long period of time, if you’ve
not corrected this,
one would never think that, you know,
this has such serious sequelae,
but it does. You can’t just allow
for bile to remain stasis.
You can’t. Bile has all kinds
Look for complications, empyema,
gangrene, gallstone ileus.
So from now on, apart from your normal
presentation that you’re so accustomed to,
understand that you need
to take out the stone.
You need to, maybe perhaps,
take out the gallbladder.
If you don’t, the complications become
Remember that stasis I was
talking to you about?
If you don’t remove the stone,
and maybe perhaps
if you don’t correct the issue,
at some point in time,
infection's going to set in.
And when it does,
you call this cholangitis.
High fever with chills and
hypotension, associated with
the gram-negative bacteremia.
Now, critically ill, high mortality.
There you are.
There is a patient undergoing
stasis of the bile and such
and infection has kicked in with
gram-negative organism, bacteremia,
keep going, uh-oh,
septicemia, sepsis, death.
See what I’m getting at? It’s a story,
but you need to make sure
that you know how to deal
with this story properly
and deal with your
Our topic now is still gallstone.
I want you to move the
stone out of the gallbladder.
We talked cholecystitis,
we talked about how that stone
caused obstructive jaundice,
we talked about infection may set in,
may result in cholangitis.
What if the stone makes
its way down?
Now picture the anatomy that
I walked you through quickly.
And it comes down the common
Along with the pancreatic duct,
they’re supposed to hook up, right?
But if you had that stone now
here by the common bile duct,
not only are you going to have
damage to the gallbladder and the tree,
you’re also going to have
damage to the pancreas.
Usually, because of the
it'd be chronic pancreatitis.
Acute impaction of gallstone in the ampulla
of Vater. Think about where that is.
Most stones, thank goodness,
will pass spontaneously,
but there’s every possibility
that it might get stuck.
Urgent ERCP to extract the
stone improves the outcome.