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

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Definitions
Symptomatic cholelithiasis Acute cholecystitis Chronic cholecystitis Acalculous cholecystitis Choledocholithiasis Cholangitis 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, +Murphys = inspiratory arrest Recurrent bouts of colic/acute choly leading to chronic GB wall inflamm/fibrosis. No fever/WBC. GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts Gallstone in the common bile duct (primary means originated there, secondary = from GB) 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 > 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

Cholelithiasis

Symptomatic cholelithiasis can be a herald to:

an attack of acute cholecystitis or ongoing chronic cholecystitis

Asymptomatic Symptomatic cholelithiasis cholelithiasis

May also resolve

Chronic calculous cholecystitis Acute calculous cholecystitis

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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 > 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 (>4mm), 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 >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

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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 More commonly in men and diabetics. Severe cholecystitis 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 > 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 > 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