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
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“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
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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
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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
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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