Gallstone Disease Tad Kim, M.D. Connie Lee, M.D.
Gallstone Disease Gallstone Disease Tad Kim, M.D. Connie Lee, M.D. Gallstone Disease Definitions • Cholelithiasis = gallstones • Acute calculous cholecystitis = 2/2 occlusion of the cystic duct by gallstone leading to gallbladder inflammation • Chronic calculous cholecystitis = recurrent episodes of cystic duct obstruction leading to scarring and a nonfunctional gallbladder • Chronic acalculous cholecystitis = symptoms of biliary colic, no gallstones, and an abnormal gallbladder ejection fraction • Acute cholangitis = bacterial infection of the biliary ducts • Choledocholithiasis = CBD stones • Mirizzi syndrome = when gallstones lodged in either the cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct (CHD), causing symptoms of obstructive jaundice Gallstone Disease Bile • Bile – Bile salts (primary: cholic, chenodeoxycholic acids; secondary: deoxycholic, lithocholic acids) – Phospholipids (90% lecithin) – Cholesterol • Cholesterol solubility depends on the relative concentration of cholesterol, bile salts, and phospholipid Gallstone Disease Types of Gallstones • Mixed (80%) • Pure cholesterol (10%) • Pigmented (10%) – Black stones (contain Ca bilirubinate, a/w cirrhosis and hemolysis) – Brown stones (a/w biliary tract infection) Gallstone Disease Gallstone Pathogenesis • Pathogenesis of cholesterol gallstones involves: (1) cholesterol supersaturation in bile, (2) crystal nucleation, (3) gallbladder dysmotility, (4) gallbladder absorption • Black pigment stones: contain Ca++ salts, a/w hemolytic conditions or cirrhosis, found in the gallbladder • Brown pigment stones: Asians, contain Ca++ palmitate, found in bile ducts, a/w biliary dysmotility and bacterial infection Gallstone Disease Gallstone Risk Factors • • • • • • • • • • • • • • • “Female, Fat, Forty, Fertile” Oral contraceptives Obesity Rapid weight loss (gastric bypass pts) Fatty diet DM Prolonged fasting TPN Ileal resection Hemolytic states Cirrhosis Bile duct stasis (biliary stricture, congenital cysts, pancreatitis, sclerosing cholangitis) IBD Vagotomy Hyperlipidemia Gallstone Disease Gallstone Complications • Gallstone ileus, gallstone pancreatitis • Acute cholecystitis: 10-20% of pts w/ symptomatic gallstones – GB gangrene – GB perforation – GB empyema (pus in the GB) – Emphysematous cholecystitis (a/w GB vascular compromise, stones, impaired immune system, infection w/gas-forming organisms - clostridium, E. coli, Klebsiella) – Cholecystoenteric fistula • Choledochohlithiasis: 8-15% of pts w/ symptomatic gallstones – Cirrhosis – Cholangitis – Pancreatitis Gallstone Disease Symptomatic Gallstones • • • • Provocation/Timing: meals (50%), nighttime Quality: constant Radiation: RUQ to the R scapula (Boas’ sign) Severity: “severe” • PE: (+)Murphy’s sign Gallstone Disease RUQ DDx • Gallbladder: cholecystitis, choledocholithiasis, cholangitis • Duodenal ulcer • Hepatitis • Appendicitis (atypical presentation) • PNA • Pancreatitis Gallstone Disease Labs • Order: BMP, amylase/lipase, LFTs, CBC, coags • Acute cholecystitis: increased WBC, increased alk phos, slight increase in amylase and T bili Gallstone Disease Imaging • KUB - only 15% of gallstones are radiopaque • U/S - gallstone identification false(-) rate is 5-15%. It identifies bile duct dilatation w/ 80% accuracy. – Look for: thickened GB wall (>3mm), pericholecystic fluid, distended GB, Murphy’s sign • HIDA scan - radionuclide IV, extracted from blood, excreted into bile – Uptake by liver, GB, CBD, duodenum w/in 1hr = normal – Slow uptake = hepatic parenchymal disease – Filling of GB/CBD w/delayed or absent filling of intestine = obstruction of ampulla – Non-visualization of GB w/ filling of the CBD and duodenum = cystic duct obstruction and acute cholecystitis (95% sensitivity & specificity) • CT scan - used to diagnose complications • MRI - can detect gallstones and common duct stones • ERCP - to look for CBD stones Gallstone Disease Ultrasonographic Images of Three Gallbladders Strasberg S. N Engl J Med 2008;358:2804-2811 Gallstone Disease Hepatobiliary Scintigraphy Strasberg S. N Engl J Med 2008;358:2804-2811 Gallstone Disease CT Scan of the Abdomen Thomas L et al. N Engl J Med 1999;341:1134-1138 Gallstone Disease Diagnostic Criteria for Acute Cholecystitis, According to Tokyo Guidelines Strasberg S. N Engl J Med 2008;358:2804-2811 Gallstone Disease Cholecystitis: Management • NPO, IVF, IV antibiotics • Non-operative: dissolution therapy ursodeoxycholic acid, chenodeoxycholic acid • Operative: cholecystectomy • For unstable pts: percutaneous transhepatic cholecystostomy (CT or U/S guided) Gallstone Disease Indications for Prophylactic Cholecystectomy • • • • • • Pediatric gallstones Congenital hemolytic anemia Gallstones >2.5cm Porcelain gallbladder Bariatric surgery Incidental gallstones found during intraabdominal surgery • Recommended prior to transplantation Gallstone Disease Case 1 • HPI: 46y F p/w 4hr h/o nausea and RUQ pain radiating to the R scapula. Symptoms began 1 hr after a fatty meal. Pt currently has no pain. No prior episodes. • PMHx/PSHx None • PE: RUQ minimally TTP, (-)Murphy’s • Labs: WBC 8, LFT normal • Studies: RUQ U/S w/cholelithiasis without GB wall thickening or pericholecystic fluid • What is the diagnosis? Gallstone Disease Case 1 • → denotes gallstones → → ► • ► denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone Gallstone Disease Case 1: Continued • Dx: symptomatic cholethiasis • Plan: NPO, IVF, cholecystectomy Gallstone Disease Case 2 • 46y F p/w 4hr h/o nausea and RUQ pain radiating to the R scapula. Symptoms began 1 hr after a fatty meal. Pt currently has no pain. Has had multiple similar episodes. • PMHx/PSHx None • PE: RUQ minimally TTP, (-)Murphy’s • Labs: WBC 6, LFT normal • Studies: RUQ U/S w/cholelithiasis without GB wall thickening or pericholecystic fluid • Diagnosis: ? Gallstone Disease Case 2: Continued • Dx: chronic calculous cholecystitis • Recurrent inflammatory process due to recurrent cystic duct obstruction leading to scarring/wall thickening • Treatment: cholecystectomy Gallstone Disease Case 3 • 46yF p/w h/o >24hr of RUQ pain radiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever • Exam: Febrile, RUQ TTP, (+)Murphy’s sign • Labs: WBC 13, Mild ↑LFT • U/S: gallstones, wall thickening, GB distension, pericholecystic fluid, sonographic Murphy’s sign • What is the diagnosis? Gallstone Disease Case 3: Continued • Curved arrow – Two small stones at GB neck ◄ • Straight arrow – Thickened GB wall • ◄ – pericholecystic fluid = dark lining outside the wall Gallstone Disease Case 3: Continued → ► • → denotes the GB wall thickening • ► denotes the fluid around the GB • GB also appears distended Gallstone Disease Case 3: Continued • Dx: acute calculous cholecystitis • Persistent cystic duct obstruction leads to GB distension, wall inflammation & edema • Risk of: empyema, gangrene, rupture • Treatment: – NPO – IVF – ABX: • Common organisms: E coli, Bacteroides fragilis, Klebsiella, Enterococcus, and Pseudomonas • Piperacillin/tazobactam (Zosyn), ampicillin/sulbactam (Unasyn), or meropenem – Cholecystectomy Gallstone Disease Case 4 • 87y M critically ill, on long-term TPN c/o RUQ pain • PE: febrile, RUQ TTP • U/S: GB wall thickening, pericholecystic fluid, no gallstones • What is the diagnosis? Gallstone Disease Case 4: Continued • Dx: acute acalculous cholecystitis • Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin • Risk of: gangrene, empyema, perforation due to ischemia • TX: cholecystectomy • If pt is too sick, percutaneous cholecystostomy tube followed by cholecystectomy Gallstone Disease Case 5 • 46y F p/w RUQ pain, jaundice, acholic stools, dark tea-colored urine, w/o fever • PMHx: cholelithiasis • Exam: unremarkable • WBC 8, T.Bili 8, AST/ALT NL, Hep B/C neg • U/S: gallstones, CBD stone, dilated CBD > 1cm • What is the diagnosis? Gallstone Disease Case 5: Continued • DX: choledocholithiasis • Similar presentation as cholelithiasis, except with the addition of jaundice • DDx: cholelithiasis, hepatitis, cholangitis, CA, choledochal cyst, bile duct stricture, UC, pancreatitis • Plan: – Endoscopic retrograde cholangiopancreatography (ERCP) w/ stone extraction and sphincterotomy – Interval cholecystectomy after recovery from ERCP Gallstone Disease Case 6 • 46y F p/w fever, RUQ pain, jaundice • PE: tachycardic, hypotensive, RUQ pain • Immediate management: – ABC – Resuscitate – CBC, LFTs, blood cultures – Abdominal U/S • What is the diagnosis? • What is the plan? Gallstone Disease Case 6: Continued • Dx: cholangitis • Infection of the bile ducts due to CBD obstruction secondary to stones/strictures • Common organisms: E. coli, Klebsiella, Pseudomonas, Enterobacter, Proteus, Serratia • 70% p/w Charcot’s • May lead to life-threatening sepsis and septic shock (Raynaud’s pentad) • Common lab findings: leukocytosis, hyperbili, elevated alk phos • Treatment: – NPO, IVF, IV ABX – Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC) Gallstone Disease Case 7 • • • • • • 46y F p/w persistent epigastric & back pain PMHx: symptomatic gallstones SHx: no ETOH PE: Tender epigastrum Labs: Amylase 2000, ALT 150 U/S: gallstones • What is the diagnosis? • What is the plan? Gallstone Disease Case 7: Continued • Dx: gallstone pancreatitis • 35% of acute pancreatitis secondary 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 • Treatment: – ABC, resuscitate, NPO/IVF, pain medication – ERCP once pancreatitis resolves – Cholecystectomy before d/c Gallstone Disease Take Home Points • Start with ABCs • Cholelithiasis = “Female, Fat, Forty, Fertile” • Stone formation based on the relative concentration of cholesterol, bile salts, and phospholipid • Cholecystitis PE = Murphy’s sign • RUQ evaluation: U/S, HIDA, CT, MRI, ERCP • Acalculous cholecystitis a/w TPN, ICU setting • Cholangitis = Charcot’s triad, Reynold’s pentad
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