Gallstone Disease Lee

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Gallstone Disease

Gallstone Disease


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Gallstone Disease

Definitions

Cholelithiasis = gallstones

Acute calculous cholecystitis = 2/2 occlusion of the cystic ductby gallstone leading to gallbladder inflammation

Chronic calculous cholecystitis = recurrent episodes of cysticduct obstruction leading to scarring and a nonfunctionalgallbladder

Chronic acalculous cholecystitis = symptoms of biliary colic, nogallstones, 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 cysticduct or the Hartmann pouch of the gallbladder, externallycompressed the common hepatic duct (CHD), causingsymptoms of obstructive jaundice


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Gallstone Disease

Bile

Bile

Bile salts (primary: cholic, chenodeoxycholic acids;secondary: deoxycholic, lithocholic acids)

Phospholipids (90% lecithin) Cholesterol

Cholesterol solubility depends on the relativeconcentration of cholesterol, bile salts, and

phospholipid


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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)


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Gallstone Pathogenesis

Pathogenesis of cholesterol gallstones involves: (1)cholesterol supersaturation in bile, (2) crystalnucleation, (3) gallbladder dysmotility, (4) gallbladder

absorption

Black pigment stones: contain Ca++ salts, a/whemolytic conditions or cirrhosis, found in thegallbladder

Brown pigment stones: Asians, contain Ca++palmitate, found in bile ducts, a/w biliary dysmotilityand bacterial infection


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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


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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 vascularcompromise, stones, impaired immune system, infectionw/gas-forming organisms - clostridium, E. coli, Klebsiella)

Cholecystoenteric fistula

Choledochohlithiasis: 8-15% of pts w/ symptomatic gallstones

Cirrhosis

Cholangitis

Pancreatitis


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Symptomatic Gallstones

Provocation/Timing: meals (50%), nighttime

Quality: constant

Radiation: RUQ to the R scapula (Boas sign) Severity: severe

PE: (+)Murphys sign


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RUQ DDx

Gallbladder: cholecystitis, choledocholithiasis,cholangitis

Duodenal ulcer

Hepatitis Appendicitis (atypical presentation)

PNA

Pancreatitis


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Labs

Order: BMP, amylase/lipase, LFTs, CBC,coags

Acute cholecystitis: increased WBC,

increased alk phos, slight increase inamylase and T bili


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Imaging KUB - only 15% of gallstones are radiopaque

U/S - gallstone identification false(-) rate is 5-15%. It identifiesbile duct dilatation w/ 80% accuracy.

Look for: thickened GB wall (>3mm), pericholecystic fluid,distended GB, Murphys 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


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Strasberg S. N Engl J Med 2008;358:2804-2811

Ultrasonographic Images of Three Gallbladders

G


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Hepatobiliary Scintigraphy

G ll Di


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Thomas L et al. N Engl J Med 1999;341:1134-1138

CT Scan of the Abdomen

G ll t Di


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Diagnostic Criteria for Acute Cholecystitis, According to Tokyo Guidelines

G ll t Di


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Cholecystitis: Management

NPO, IVF, IV antibiotics

Non-operative: dissolution therapy ursodeoxycholicacid, chenodeoxycholic acid

Operative: cholecystectomy

For unstable pts: percutaneous transhepaticcholecystostomy (CT or U/S guided)

G ll t Di


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Indications for Prophylactic Cholecystectomy

Pediatric gallstones

Congenital hemolytic anemia

Gallstones >2.5cm

Porcelain gallbladder

Bariatric surgery

Incidental gallstones found during intraabdominalsurgery

Recommended prior to transplantation

Gallstone Disease


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Case 1

HPI: 46y F p/w 4hr h/o nausea and RUQ pain radiatingto the R scapula. Symptoms began 1 hr after a fattymeal. Pt currently has no pain. No prior episodes.

PMHx/PSHx None

PE: RUQ minimally TTP, (-)Murphys

Labs: WBC 8, LFT normal

Studies: RUQ U/S w/cholelithiasis without GB wall

thickening or pericholecystic fluid

What is the diagnosis?

Gallstone Disease


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Case 1

denotesgallstones

denotes theacoustic shadowdue to absence ofreflected sound

waves behind thegallstone

Gallstone Disease


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Case 1: Continued

Dx: symptomatic cholethiasis

Plan: NPO, IVF, cholecystectomy

Gallstone Disease


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Case 2

46y F p/w 4hr h/o nausea and RUQ pain radiating to theR scapula. Symptoms began 1 hr after a fatty meal. Ptcurrently has no pain. Has had multiple similarepisodes.

PMHx/PSHx None

PE: RUQ minimally TTP, (-)Murphys

Labs: WBC 6, LFT normal

Studies: RUQ U/S w/cholelithiasis without GB wallthickening or pericholecystic fluid

Diagnosis: ?

Gallstone Disease


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Case 2: Continued

Dx: chronic calculous cholecystitis

Recurrent inflammatory process due to

recurrent cystic duct obstruction leading toscarring/wall thickening

Treatment: cholecystectomy

Gallstone Disease


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Case 3

46yF p/w h/o >24hr of RUQ pain radiating to the Rscapula, started after fatty meal, a/w nausea, vomiting,fever

Exam: Febrile, RUQ TTP, (+)Murphys sign

Labs: WBC 13, Mild LFT

U/S: gallstones, wall thickening, GB distension,pericholecystic fluid, sonographic Murphys sign


Gallstone Disease


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Case 3: Continued

Curved arrow Two small stones

at GB neck

Straight arrow Thickened GB wall

pericholecysticfluid = dark liningoutside the wall

Gallstone Disease


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Case 3: Continued

denotes the GB

wall thickening

denotes the fluidaround the GB

GB also appearsdistended

Gallstone Disease


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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


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Case 4

87y M critically ill, on long-term TPN c/oRUQ pain

PE: febrile, RUQ TTP

U/S: GB wall thickening, pericholecysticfluid, no gallstones


Gallstone Disease


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Case 4: Continued

Dx: acute acalculous cholecystitis

Caused by gallbladder stasis from lack of enteralstimulation by cholecystokinin

Risk of: gangrene, empyema, perforation due toischemia

TX: cholecystectomy

If pt is too sick, percutaneous cholecystostomytube followed by cholecystectomy

Gallstone Disease


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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


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Case 5: Continued

DX: choledocholithiasis

Similar presentation as cholelithiasis, except with theaddition 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 fromERCP

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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 plan?

Gallstone Disease


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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 Charcots May lead to life-threatening sepsis and septic shock (Raynauds

pentad)

Common lab findings: leukocytosis, hyperbili, elevated alk phos

Treatment:

NPO, IVF, IV ABX

Emergent decompression via ERCP or perc transhepaticcholangiogram (PTC)

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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 plan?

Gallstone Disease


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Case 7: Continued

Dx: gallstone pancreatitis 35% of acute pancreatitis secondary to stones

Pathophysiology: reflux of bile into pancreatic ductand/or obstruction of ampulla by stone

ALT >150 (3-fold elevation) has 95% PPV for diagnosinggallstone pancreatitis

Treatment:

ABC, resuscitate, NPO/IVF, pain medication

ERCP once pancreatitis resolves

Cholecystectomy before d/c

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Take Home Points

Start with ABCs Cholelithiasis = Female, Fat, Forty, Fertile

Stone formation based on the relative concentration ofcholesterol, bile salts, and phospholipid

Cholecystitis PE = Murphys sign

RUQ evaluation: U/S, HIDA, CT, MRI, ERCP

Acalculous cholecystitis a/w TPN, ICU setting

Cholangitis = Charcots triad, Reynolds pentad

Gallstone Disease Lee

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