Gallstones Disease
Gallstone Disease
Tad Kim, M.D.
UF Surgery
[email protected]
(c) 682-3793; (p) 413-3222
Gallstones Disease
Overview
• Gallstone pathogenesis
• Definitions
• Differential Diagnosis of RUQ pain
• 7 Cases
Gallstones Disease
Gallstone Pathogenesis
• Bile = bile salts, phospholipids, cholesterol
– Also bilirubin which is conjugated b4 excretion
• Gallstones due to imbalance rendering
cholesterol & calcium salts insoluble
• Pathogenesis involves 3 stages:
– 1. cholesterol supersaturation in bile
– 2. crystal nucleation
– 3. stone growth
Gallstones Disease
Definitions
Symptomatic
cholelithiasis
Chronic
cholecystitis
Wax/waning postprandial epigastric/RUQ pain
due to transient cystic duct obstruction by stone,
no fever/WBC, normal LFT
Acute GB inflammation due to cystic duct
obstruction. Persistent RUQ pain +/- fever,
↑WBC, ↑LFT, +Murphy’s = inspiratory arrest
Recurrent bouts of colic/acute chol’y leading to
chronic GB wall inflamm/fibrosis. No fever/WBC.
Acalculous
cholecystitis
GB inflammation due to biliary stasis(5% of time)
and not stones(95%). Seen in critically ill pts
Choledocholithiasis
Gallstone in the common bile duct (primary
means originated there, secondary = from GB)
Cholangitis
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
Acute
cholecystitis
Gallstones Disease
Differential Diagnosis of RUQ pain
• Biliary disease
– Acute chol’y, chronic chol’y, CBD stone,
cholangitis
• Inflamed or perforated duodenal ulcer
• Hepatitis
• Also need to rule out:
– Appendicitis, renal colic, pneumonia or
pleurisy, pancreatitis
Gallstones Disease
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: ?
Gallstones Disease
Case 1
• → denotes
gallstones
→
→
►
• ► denotes the
acoustic shadow
due to absence
of reflected
sound waves
behind the
gallstone
Gallstones Disease
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
Gallstones Disease
Spectrum of Gallstone Disease
• Symptomatic
cholelithiasis can
be a herald to:
Cholelithiasis
Asymptomatic Symptomatic
cholelithiasis cholelithiasis
– an attack of acute
cholecystitis
– or ongoing chronic
cholecystitis
• May also resolve
Chronic
calculous
cholecystitis
Acute
calculous
cholecystitis
Gallstones Disease
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: ?
Gallstones Disease
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
Gallstones Disease
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: ?
Gallstones Disease
Case 3
• Curved arrow
– Two small stones
at GB neck
◄
• Straight arrow
– Thickened GB wall
• ◄
– pericholecystic
fluid = dark lining
outside the wall
Gallstones Disease
Case 3
→
• → denotes the GB
wall thickening
►
• ► denotes the
fluid around the
GB
• GB also appears
distended
Gallstones Disease
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
– If U/S non-diagnostic, obtain HIDA
• Tx: NPO, IVF, Abx (GNR & enterococcus)
• Sg: Cholecystectomy usu within 48hrs
Gallstones Disease
Case 4
• 87yo M critically ill, on long-term TPN w
RUQ pain, fever, ↑WBC
• Ultrasound: GB wall thickening,
pericholecystic fluid, no gallstones
• Diagnosis: ?
Gallstones Disease
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
Gallstones Disease
Complications of acute cholecystitis
Empyema of
gallbladder
Pus-filled GB due to bacterial proliferation in
obstructed GB. Usu. more toxic, high fever
Emphysematous More commonly in men and diabetics. Severe
cholecystitis
RUQ pain, generalized sepsis. Imaging
Perforated
gallbladder
shows air in GB wall or lumen
Occurs in 10% of acute chol’y, usually
becomes a contained abscess in RUQ
Less commonly, perforates into adjacent
viscus = cholecystoenteric fistula & the stone
can cause SBO (gallstone ileus)
Gallstones Disease
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
• Diagnosis: ?
Gallstones Disease
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)
– Stone extraction and sphincterotomy
• Interval cholecystectomy after recovery
from ERCP
Gallstones Disease
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
– 2 large bore IV, Foley, Continuous monitor
– 1-2L fluid bolus, repeat until resuscitated
• Diagnosis: ?
Gallstones Disease
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
Gallstones Disease
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: ?
Gallstones Disease
Gallstone pancreatitis
• 35% of acute pancreatitis 2ndary to stones
• Pathophysiology
– 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
Gallstones Disease
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