Gallstone Disease

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Gallstone Disease

• Tad Kim, M.D.
• UF Surgery
• tad.kim_at_surgery.ufl.edu
• (c) 682-3793 (p) 413-3222

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Overview

• Gallstone pathogenesis
• Definitions
• Differential Diagnosis of RUQ pain
• 7 Cases

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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

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Definitions
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, Murphys inspiratory arrest
Chronic cholecystitis Recurrent bouts of colic/acute choly 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
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Differential Diagnosis of RUQ pain

• Biliary disease
• Acute choly, chronic choly, CBD stone,
  cholangitis
• Inflamed or perforated duodenal ulcer
• Hepatitis
• Also need to rule out
• Appendicitis, renal colic, pneumonia or pleurisy,
  pancreatitis

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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 Murphys
• WBC 8, LFT normal
• RUQ U/S reveals cholelithiasis without GB wall
  thickening or pericholecystic fluid
• Diagnosis ?

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Case 1

• ? denotes gallstones
• ? denotes the acoustic shadow due to absence of
  reflected sound waves behind the gallstone

?
?
?
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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 gt 24hrs
• Ultrasound reveals evidence at the crime scene of
  the likely etiology gallstones
• Exam, WBC, and LFT normal in this case
• Treatment Laparoscopic cholecystectomy

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Spectrum of Gallstone Disease

• Symptomatic cholelithiasis can be a herald to
• an attack of acute cholecystitis
• or ongoing chronic cholecystitis
• May also resolve

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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 ?

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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

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Case 3

• Same pt, now gt 24hrs of RUQ pain radiating to the
  R scapula, started after fatty meal, a/w nausea,
  vomiting, fever
• Exam Palpable, tender gallbladder, guarding,
  Murphys inspiratory arrest
• WBC 13, Mild ?LFT
• U/S gallstones, wall thickening (gt4mm), GB
  distension, pericholecystic fluid, sonographic
  Murphys sign (very specific)
• Diagnosis ?

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Case 3

• Curved arrow
• Two small stones at GB neck
• Straight arrow
• Thickened GB wall
• ?
• pericholecystic fluid dark lining outside the
  wall

?
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Case 3

• ? denotes the GB wall thickening
• ? denotes the fluid around the GB
• GB also appears distended

?
?
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Acute calculous cholecystitis

• Persistent cystic duct obstruction leads to GB
  distension, wall inflammation edema
• Can lead to empyema, gangrene, rupture
• Pain usu. persists gt24hrs 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

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Case 4

• 87yo M critically ill, on long-term TPN w RUQ
  pain, fever, ?WBC
• Ultrasound GB wall thickening, pericholecystic
  fluid, no gallstones
• Diagnosis ?

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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

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Complications of acute cholecystitis
Empyema 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 choly, usually becomes a contained abscess in RUQ
Less commonly, perforates into adjacent viscus cholecystoenteric fistula the stone can cause SBO (gallstone ileus)
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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 gt
  1cm
• Diagnosis ?

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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

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Case 6

• 46yo F p/w fever, RUQ pain, jaundice (Charcots
  triad)
• If also altered mental status and signs of shock
  Raynauds pentad
• VS tachycardic, hypotensive
• ABCs, Resuscitate
• 2 large bore IV, Foley, Continuous monitor
• 1-2L fluid bolus, repeat until resuscitated
• Diagnosis ?

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Cholangitis

• Infection of the bile ducts due to CBD
  obstruction 2ndary to stones, strictures
• Charcots triad seen in 70 of pts
• May lead to life-threatening sepsis and septic
  shock (Raynauds pentad)
• Tx NPO, IVF, IV Abx
• Emergent decompression via ERCP or perc
  transhepatic cholangiogram (PTC)
• Used to require emergency laparotomy

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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 ?

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Gallstone pancreatitis

• 35 of acute pancreatitis 2ndary to stones
• Pathophysiology
• Reflux of bile into pancreatic duct and/or
  obstruction of ampulla by stone
• ALT gt 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

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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 Murphys)
• 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