Gallstone Disease

Gallstone Disease
By:Tad Kim, M.D.

Overview
* Gallstone pathogenesis
* Definitions
* Differential Diagnosis of RUQ pain
* 7 Cases

Gallstone Pathogenesis
* Bile = bile salts, phospholipids, cholesterol
o Also bilirubin which is conjugated b4 excretion
* Gallstones due to imbalance rendering cholesterol & calcium salts insoluble
* Pathogenesis involves 3 stages:
o 1. cholesterol supersaturation in bile
o 2. crystal nucleation
o 3. stone growth

Definitions
Infection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic shock

Cholangitis
Gallstone in the common bile duct (primary means originated there, secondary = from GB)

Choledocho-lithiasis
GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts

Acalculous cholecystitis
Recurrent bouts of colic/acute chol’y leading to chronic GB wall inflamm/fibrosis. No fever/WBC.

Chronic cholecystitis
Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrest

Acute cholecystitis
Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT

Symptomatic cholelithiasis
Differential Diagnosis of RUQ pain

* Biliary disease
o Acute chol’y, chronic chol’y, CBD stone, cholangitis
* Inflamed or perforated duodenal ulcer
* Hepatitis
* Also need to rule out:
o Appendicitis, renal colic, pneumonia or pleurisy, pancreatitis
Case 1

* 46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now.
* No prior episodes
* Minimal RUQ tenderness, no Murphy’s
* WBC 8, LFT normal
* RUQ U/S reveals cholelithiasis without GB wall thickening or pericholecystic fluid
* Diagnosis: ?

Symptomatic cholelithiasis

* aka “biliary colic”
* The pain occurs due to a stone obstructing the cystic duct, causing wall tension; pain resolves when stone passes
* Pain usually lasts 1-5 hrs, rarely > 24hrs
* Ultrasound reveals evidence at the crime scene of the likely etiology: gallstones
* Exam, WBC, and LFT normal in this case
* Treatment: Laparoscopic cholecystectomy

Spectrum of Gallstone Disease
Cholelithiasis
Asymptomatic
cholelithiasis
Symptomatic
cholelithiasis
Chronic
calculous
cholecystitis
Acute
calculous
cholecystitis
* Symptomatic cholelithiasis can be a herald to:
o an attack of acute cholecystitis
o or ongoing chronic cholecystitis
* May also resolve

Case 2
* Same case, except pt has had multiple prior attacks of similar RUQ pain
* No fever or WBC
* Ultrasound reveals gallstones, thickened GB wall, no pericholecystic fluid
* Diagnosis: ?
Chronic calculous cholecystitis

* Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones
* Overtime, leads to scarring/wall thickening
* Treatment: laparoscopic cholecystectomy

Case 3
* Same pt, now > 24hrs of RUQ pain radiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever
* Exam: Palpable, tender gallbladder, guarding, +Murphy’s = inspiratory arrest
* WBC 13, Mild LFT
* U/S: gallstones, wall thickening (>4mm), GB distension, pericholecystic fluid, sonographic Murphy’s sign (very specific)
* Diagnosis: ?
* Curved arrow
o Two small stones at GB neck
* Straight arrow
o Thickened GB wall
* GB also appears distended

Acute calculous cholecystitis
* Persistent cystic duct obstruction leads to GB distension, wall inflammation & edema
* Can lead to: empyema, gangrene, rupture
* Pain usu. persists >24hrs & a/w N/V/Fever
* Palpable/tender or even visible RUQ mass
* Nuclear HIDA scan shows nonfilling of GB
o If U/S non-diagnostic, obtain HIDA
* Tx: NPO, IVF, Abx (GNR & enterococcus)
* Sg: Cholecystectomy usu within 48hrs
* 87yo M critically ill, on long-term TPN w RUQ pain, fever, WBC
* Ultrasound: GB wall thickening, pericholecystic fluid, no gallstones

Acute acalculous cholecystitis
* In 5-10% of cases of acute cholecystitis
* Seen in critically ill pts or prolonged TPN
* More likely to progress to gangrene, empyema, perforation due to ischemia
* Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin
* Tx: Emergent cholecystectomy usu open
* If pt is too sick, perc cholecystostomy tube and interval cholecystectomy later on

Complications of acute cholecystitis
Less commonly, perforates into adjacent viscus = cholecystoenteric fistula & the stone can cause SBO (gallstone ileus)
Occurs in 10% of acute chol’y, usually becomes a contained abscess in RUQ
Perforated gallbladder
More commonly in men and diabetics. Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumen
Emphysematous cholecystitis
Pus-filled GB due to bacterial proliferation in obstructed GB. Usu. more toxic, high fever
Empyema of gallbladder

Case 5
* 46yo F p/w RUQ pain, jaundice, acholic stools, dark tea-colored urine, no fevers
* Known history of cholelithiasis
* Exam: unremarkable
* WBC 8, T.Bili 8, AST/ALT NL, HepB/C neg
* Ultrasound: Gallstones, CBD stone, dilated CBD > 1cm

Choledocholithiasis
* Can present similarly to cholelithiasis, except with the addition of jaundice
* DDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with pain
* Tx: Endoscopic retrograde cholangiopancreatography (ERCP)
o Stone extraction and sphincterotomy
* Interval cholecystectomy after recovery from ERCP

Case 6
* 46yo F p/w fever, RUQ pain, jaundice (Charcot’s triad)
* If also altered mental status and signs of shock = Raynaud’s pentad
* VS tachycardic, hypotensive
* ABC’s, Resuscitate
o 2 large bore IV, Foley, Continuous monitor
o 1-2L fluid bolus, repeat until resuscitated
* Diagnosis: ?

Cholangitis
* Infection of the bile ducts due to CBD obstruction 2ndary to stones, strictures
* Charcot’s triad seen in 70% of pts
* May lead to life-threatening sepsis and septic shock (Raynaud’s pentad)
* Tx: NPO, IVF, IV Abx
* Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC)
* Used to require emergency laparotomy

Case 7
* 46yo F p/w persistent epigastric & back pain
* Known history of symptomatic gallstones
* No EtOH abuse
* Exam: Tender epigastrum
* Amylase 2000, ALT 150
* Ultrasound: Gallstones
* Diagnosis: ?

Gallstone pancreatitis
* 35% of acute pancreatitis 2ndary to stones
* Pathophysiology
o Reflux of bile into pancreatic duct and/or obstruction of ampulla by stone
* ALT > 150 (3-fold elevation) has 95% PPV for diagnosing gallstone pancreatitis
* Tx: ABC, resuscitate, NPO/IVF, pain meds
* Once pancreatitis resolving, ERCP w stone extraction/sphincterotomy
* Cholecystectomy before hospital discharge

Take Home Points
* As always, ABC & Resuscitate before Dx
* Understanding the definitions is key
* Is this acute cholecystitis? (fever, WBC, tender on exam with positive Murphy’s)
* Or simply cholelithiasis vs ongoing chronic cholecystitis? (no fever/WBC)
* Is patient sick or toxic-appearing, to suspect empyema, gangrene or even perforation?
* Elicit h/o jaundice, acholic stools, tea-colored urine
* Rule out cholangitis, because this will kill the patient unless dx & tx early

Gallstones Disease.ppt