13 February 2010

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

0 comments:

All links posted here are collected from various websites. No video or powerpoint files are uploaded on this blog. If you are the original author and do not wish to display your content on this blog please Email me anandkumarreddy at gmail dot com I will remove it. The contents of this blog are meant for educational purpose and not for commercial use. If you use any content give due credit to the original author.

This site uses cookies from Google to deliver its services, to personalise ads and to analyse traffic. Information about your use of this site is shared with Google. By using this site, you agree to its use of cookies.

  © Blogger templates Newspaper III by Ourblogtemplates.com 2008

Back to TOP