 In this video I want to talk about the complications of gallstones. We are going to start with gallstones. You might be confronted with a patient with gallstones, you might be confronted with gallstones in the exams. What do you do? How do you think about the complications of gallstones? Well, there is one easy way to go about it and that is to think back at your anatomy. You did anatomy at med school and it was important for this specific reason thinking about the complications of a disease based on the anatomy. Now think of the anatomy of the biliary tree. You can really just open a book or just bring it up from long lost memory. You have a gallbladder. From the gallbladder there is a tiny little duct called the cystic duct. It joins up with a common hepatic duct to form the common bile duct and that common hepatic duct, remember, it splits in two and then goes into the left and right lobes of the liver. That common bile duct comes all the way down and joins with the pancreatic duct into the duodenum and it really depends where those stones are that will give you these complications. Now the vast majority of patients with gallstones, remember, will not have any symptoms at all. Those are actually quite dangerous patients because you'll do an ultrasound for some vague abdominal discomfort symptoms and gallstones will be discovered. Now are those gallstones the cause of this problem? It is really something that you have to deal with. In many situations we'll do an upper GI endoscopy just to look for pathology because, remember, this upper GI area can have very similar symptoms. All the diseases of the upper GI take can have very similar symptoms at least and you've got to be very careful. Just to discover gallstones on an ultrasound does not mean you necessarily have to do something about it. So the first thing is, gallstones in the gallbladder, no symptoms whatsoever or some vague symptom that might not be related to the gallbladder at all because, remember, you don't want to take out or send your patient to have their gallbladder removed and the patient comes back and the symptoms are still there because they were never related to the gallstones. That's a horrible situation. So asymptomatic is the first one. Now the stones are in the gallbladder. One of the first proper symptoms, I'm going to call these symptoms really a disease, not really a complication. Well, let's call them a complication for now. So the gallbladder contracts after eating and the stone goes into the little neck of the gallbladder and gets stuck. It can't go into the cystic duct. This gallbladder is trying to contract to express the bile. It cannot, and there's tension in that system and it really is extremely painful. That stone falls back. Suddenly there's a release of that high pressure and all the symptoms are gone. So it's this patient with a while after eating getting these intermittent, very severe pain and it disappears. It's called biliary colic. So that is the first real complication. It's called a complication of gallstones. The second one is where this might become an acute thing that that stone is stuck and some real inflammation sets and leading to colisostitis. The whole gallbladder is inflamed. There might be bacterial overgrowth. We never know if there are bacteria or not just when we see simple colisostitis and hence we always give antibiotics or acute colisostitis. What happens here though is that the pain does not go away. The pain does not to leave. It is something that goes beyond say a six hour time period and we usually have to admit those patients. When you do the white cell count it might be up and they might even be running a bit of a temperature. So anatomy, remember the gallstone is still there. When the gallstone gets beyond that into the bile duct what can happen now? Well it can get stuck in the bile duct and that can give you obstructive jaundice and if there is inflammation and infection the patient is severely ill with colonitis. Colonitis remember pain, fever and jaundice with these patients if they become septicemic of course they become hypertensive they become a bit delirious they become a bit of a septic shock that is a very serious situation. Right at the end the gallstone can go all the way down get stuck together with a pancreatic duct and now we are going to get biliary pancreatitis. It is all anatomical. Remember some of the pancreatic juice is now going to get free and we get pancreatitis. One of the rarest ones that you should never mention first of course somewhere along the line the gallstone erodes into the small bowel and it can be a direct erosion from different pathways but it can go all the way down the small bowel and it can get stuck at the aliocecal valve and we get this gallstone small bowel obstruction. Whether that is mechanical or paralysis of that area not of concern here it is extremely rare over the last couple of years I have seen a single patient with this condition so you leave that one for last. So just anatomically that is the main problem you just think about the anatomy you will answer that question exam when you see a patient you will be able to deal with the possible complications of gallstones. The patient gets sent for an ultrasound they ask you about the report that says that they have gallstones they want to know more you can explain it to them really by way of the anatomy. Now there are a few more subtleties to this remember any type of infection inflammation in the biliary tree we can get abscess formation in the local area we can get abscesses even in the liver we see that in very neglected cases locally with severe colostitis you can also see an empyema that is just a gallbladder full of pus that develops that can even rupture and you can get pus and bile into the abdomen. So just think locally where you start off with a smaller complication just expand things and make them worse liver abscess is pretty colossistic abscesses etc. Empyema that is pus in the gallbladder itself. You can do it anatomically and you will be able to get all the complications of gallstone disease.