Gallstones Disease

Gallstone Disease

Tad Kim, M.D.UF Surgery

tad.kim@surgery.ufl.edu(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 DiseaseDefinitions

Symptomatic cholelithiasis

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

Acute cholecystitis

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

Chronic cholecystitis

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

Choledocho-lithiasis

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

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

Cholelithiasis

Asymptomatic cholelithiasis

Symptomaticcholelithiasis

Chronic calculous

cholecystitis

Acute calculous

cholecystitis

• Symptomatic cholelithiasis can be a herald to:– an attack of acute

cholecystitis– or ongoing chronic

cholecystitis

• May also resolve

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 cholecystitisEmpyema of gallbladder

Pus-filled GB due to bacterial proliferation in obstructed GB. Usu. more toxic, high fever

Emphysematous cholecystitis

More commonly in men and diabetics. Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumen

Perforated gallbladder

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