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10/13/2015

Gallstones(Cholelithiasis)Workup:ApproachConsiderations,BloodStudies,AbdominalRadiography

Gallstones(Cholelithiasis)Workup
Author:DouglasMHeuman,MD,FACP,FACG,AGAFChiefEditor:JulianKatz,MDmore...
Updated:Jan20,2015

ApproachConsiderations
Patientswithuncomplicatedcholelithiasisorsimplebiliarycolictypicallyhave
normallaboratorytestresults.Laboratorytestingisgenerallynotnecessaryunless
cholecystitisisaconcern. [10]
Asymptomaticgallstonesareoftenfoundincidentallyonplainradiographs,
abdominalsonograms,orCTscanforworkupofotherprocesses.Plainradiographs
havelittleroleinthediagnosisofgallstonesorgallbladderdisease.Cholesteroland
pigmentstonesareradiopaqueandvisibleonradiographsinonly1030%of
instances,dependingontheirextentofcalcification.

BloodStudies
Inpatientswithsuspectedgallstonecomplications,bloodtestsshouldincludea
completebloodcell(CBC)countwithdifferential,liverfunctionpanel,andamylase
andlipase.
Acutecholecystitisisassociatedwithpolymorphonuclearleukocytosis.However,up
toonethirdofthepatientswithcholecystitismaynotmanifestleukocytosis.
Inseverecases,mildelevationsofliverenzymesmaybecausedbyinflammatory
injuryoftheadjacentliver.
Patientswithcholangitisandpancreatitishaveabnormallaboratorytestvalues.
Importantly,asingleabnormallaboratoryvaluedoesnotconfirmthediagnosisof
choledocholithiasis,cholangitis,orpancreatitisrather,acoherentsetoflaboratory
studiesleadstothecorrectdiagnosis.
Choledocholithiasiswithacutecommonbileduct(CBD)obstructioninitially
producesanacuteincreaseintheleveloflivertransaminases(alanineand
aspartateaminotransferases),followedwithinhoursbyarisingserumbilirubinlevel.
Thehigherthebilirubinlevel,thegreaterthepredictivevalueforCBDobstruction.
CBDstonesarepresentinapproximately60%ofpatientswithserumbilirubinlevels
greaterthan3mg/dL.
Ifobstructionpersists,aprogressivedeclineintheleveloftransaminaseswithrising
alkalinephosphataseandbilirubinlevelsmaybenotedoverseveraldays.
ProthrombintimemaybeelevatedinpatientswithprolongedCBDobstruction,
secondarytodepletionofvitaminK(theabsorptionofwhichisbile
dependent).Concurrentobstructionofthepancreaticductbyastoneintheampulla
ofVatermaybeaccompaniedbyincreasesinserumlipaseandamylaselevels.
Repeatedtestingoverhourstodaysmaybeusefulinevaluatingpatientswith
gallstonecomplications.Improvementofthelevelsofbilirubinandliverenzymes
mayindicatespontaneouspassageofanobstructingstone.Conversely,risinglevels
ofbilirubinandtransaminaseswithprogressionofleukocytosisinthefaceof
antibiotictherapymayindicateascendingcholangitiswithneedforurgent
intervention.Bloodcultureresultsarepositivein3060%ofpatientswith
cholangitis.

AbdominalRadiography
Uprightandsupineabdominalradiographsareoccasionallyhelpfulinestablishinga
diagnosisofgallstonedisease.
Blackpigmentormixedgallstonesmaycontainsufficientcalciumtoappear
radiopaqueonplainfilms.Thefindingofairinthebileductsonplainfilmsmay
indicatedevelopmentofacholedochoentericfistulaorascendingcholangitiswith
gasformingorganisms.Calcificationinthegallbladderwall(thesocalledporcelain
gallbladder)isindicativeofseverechroniccholecystitis.
Themainroleofplainfilmsinevaluatingpatientswithsuspectedgallstonedisease
istoexcludeothercausesofacuteabdominalpain,suchasintestinalobstruction,
visceralperforation,renalstones,orchroniccalcificpancreatitis.
GotoImagingofCholelithiasisforcompleteinformationonthistopic.

Ultrasonography
Ultrasonographyistheprocedureofchoiceinsuspectedgallbladderorbiliary
diseaseitisthemostsensitive,specific,noninvasive,andinexpensivetestforthe
detectionofgallstones.Moreover,itissimple,rapid,andsafeinpregnancy,andit
doesnotexposethepatienttoharmfulradiationorintravenouscontrast.Anadded
advantageisthatitcanbeperformedbyskilledpractitionersatthebedside.The
AmericanCollegeofRadiology(ACR)initsAppropriatenessCriteriarightupper
quadrantpain,publishedin2010,supportsthisconclusion. [11]
Sensitivityisvariableanddependentuponoperatorproficiency,butingeneral,itis
highlysensitiveandspecificforgallstonesgreaterthan2mm.Itislesssofor
microlithiasisorbiliarysludge.

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Ultrasonographyisveryusefulfordiagnosinguncomplicatedacutecholecystitis.The
sonographicfeaturesofacutecholecystitisincludegallbladderwallthickening(>5
mm),pericholecysticfluid,gallbladderdistention(>5cm),andasonographicMurphy
sign.Thepresenceofmultiplecriteriaincreasesitsdiagnosticaccuracy.
Gallstonesappearasechogenicfociinthegallbladder.Theymovefreelywith
positionalchangesandcastanacousticshadow.(Seetheimagebelow.)

Cholecystitiswithsmallstonesinthegallbladderneck.Classicacousticshadowingisseen
beneaththegallstones.Thegallbladderwallisgreaterthan4mm.ImagecourtesyofDT
Schwartz.

Ultrasonographyisalsohelpfulincasesofsuspectedacutecholecystitistoexclude
hepaticabscessesandotherliverparenchymalprocesses.
Whenthegallbladderiscompletelyfilledwithgallstones,thestonesmaynotbe
visibleonultrasound.However,closelyspaceddoubleechogeniclines(onefromthe
gallbladderwallandonefromthestones)withacousticshadowingmaybeevident.
(Seetheimagesbelow.)

TheWES(wallechogenicshadow)sign,longaxisofthegallbladder.Thearrowheadpointsto
thegallbladderwall.Thesecondhyperechoiclinerepresentstheedgeofthecongregated
gallstones.Acousticshadowing(AS)isreadilyseen.Thecommonbileductcanbeseenjust
abovetheportalvein(PV).ImagecourtesyofStephenMenlove.

WESsign,shortaxisviewofthegallbladder.ImagecourtesyofStephenMenlove.

Commonbileduct(CBD)stonesaremissedfrequentlyontransabdominal
ultrasonography(sensitivity,1540%).ThedetectionofCBDstonesisimpededby
thepresenceofgasintheduodenum,possiblereflectionandrefractionofthe
soundbeambycurvatureoftheduct,andthelocationoftheductbeyondthe
optimalfocalpointofthetransducer.
Ontheotherhand,dilatationoftheCBDonultrasonographicimagesisanindirect
indicatorofCBDobstruction.CBDdilatationisidentifiedaccurately,withupto90%
accuracy.However,thisfindingmaybeabsentiftheobstructionisofrecentonset.
TheusefulnessofultrasonographyfindingsasapredictorofCBDstonesisatbest
1520%.
GotoImagingofCholelithiasisforcompleteinformationonthistopic.

Endoscopicultrasound
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Endoscopicultrasound(EUS)isalsoanaccurateandrelativelynoninvasive
techniquetoidentifystonesinthedistalcommonbileduct.Sensitivityand
specificityofCBDstonedetectionarereportedinrangeof85100%. [12]

Laparoscopicultrasound
Laparoscopicultrasoundhasshownsomepromiseasaprimarymethodforbileduct
imagingduringlaparoscopiccholecystectomy. [13]Yaoetalwereabletoevaluate
thecommonbileductwithlaparoscopicultrasoundduringlaparoscopic
cholecystectomyin112of115patients(97.4%)withcholelithiasis.
Inpatientswhowerecategorizedpreoperativelyashavingalowprobabilityofbile
ductstones,theoccurrencerateofstoneswasfoundtobe7%inthosewhowere
preoperativelyassessedashavinganintermediateprobabilityofsuchstones,the
occurrenceratewas36.4%andinthosewhowereratedwiththehighestprobability
ofbileductstones,theoccurrenceratewas78.9%. [13]
Theinvestigatorssuggestedthatasexperienceincreaseswithlaparoscopic
ultrasound,thismethodmaybecomeroutineforevaluatingthebileductduring
laparoscopiccholecystectomy.Inaddition,Yaoetaladvisedmandatoryaggressive
preoperativeevaluationofthecommonbileductinthosewhoaresuspectedto
haveanintermediateorhighriskofhavingcholedocholithiasis. [13]

ComputedTomography
Computedtomography(CT)scanningismoreexpensiveandlesssensitivethan
ultrasonographyforthedetectionofgallbladderstones.CTscanningisoftenused
intheworkupofabdominalpain,asitprovidesexcellentimagesofallthe
abdominalviscera.CTscanningissuperiortoultrasonographyforthedemonstration
ofgallstonesinthedistalcommonbileduct.
GallstonesareoftenfoundincidentallyonCT.FindingsonCTforacutecholecystitis
aresimilartothosefoundonsonograms.Althoughnottheinitialstudyofchoicein
biliarycolic,CTcanbeusedindiagnosticchallengesortofurthercharacterize
complicationsofgallbladderdisease.CTisparticularlyusefulforthedetectionof
intrahepaticstonesorrecurrentpyogeniccholangitis.
GotoImagingofCholelithiasisforcompleteinformationonthistopic.

MagneticResonanceImaging
Magneticresonanceimaging(MRI)withmagneticresonance
cholangiopancreatography(MRCP)hasemergedasanexcellentimagingstudyfor
noninvasiveidentificationofgallstonesanywhereinthebiliarytract,includingthe
commonbileduct(seetheimagebelow).Becauseofitscostandtheneedfor
sophisticatedequipmentandsoftware,itisusuallyreservedforcasesinwhich
choledocholithiasisissuspected.The2010ACRguidelinesrecommendMRIasa
secondaryimagingstudyifultrasoundimagesdonotresultinacleardiagnosisof
acutecholecystitisorgallstones. [11]

Magneticresonancecholangiopancreatography(MRCP)showing5gallstonesinthecommon
bileduct(arrows).Inthisimage,bileintheductappearswhitestonesappearasdarkfilling
defects.Similarimagescanbeobtainedbytakingplainradiographsafterinjectionof
radiocontrastmaterialinthecommonbileduct,eitherendoscopically(endoscopicretrograde
cholangiography)orpercutaneouslyunderfluoroscopicguidance(percutaneoustranshepatic
cholangiography),buttheseapproachesaremoreinvasive.

GotoImagingofCholelithiasisforcompleteinformationonthistopic.

Scintigraphy
Technetium99m(99m Tc)hepatoiminodiaceticacid(HIDA)scintigraphyis
occasionallyusefulinthedifferentialdiagnosisofacuteabdominalpain.
Scintigraphygiveslittleinformationaboutnonobstructingcholelithiasisandcannot
detectotherpathologicstates,butitishighlyaccurateforthediagnosisofcystic
ductobstruction.
HIDAisnormallytakenupbytheliverandexcretedintobile,whereitfillsthe
gallbladderandcanbedetectedwithagammacamera.FailureofHIDAtofillthe
gallbladder,whileflowingfreelyintotheduodenum,isindicativeofcysticduct
obstruction.AnonvisualizinggallbladderonaHIDAscaninapatientwith
abdominalpainsupportsadiagnosisofacutecholecystitis.
AmetaanalysisbyMahidetalfoundthatpatientswithoutgallstoneswhohave
rightupperquadrantpainandapositiveHIDAscanresultaremorelikelyto
experiencesymptomreliefiftheyundergocholecystectomythaniftheyaretreated

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medically. [14]

EndoscopicRetrogradeCholangiopancreatography
Endoscopicretrogradecholangiopancreatography(ERCP)permitsradiographic
imagingofthebileducts.Inthisprocedure,anendoscopeispassedintothe
duodenumandthepapillaofVateriscannulated.Radiopaqueliquidcontrastis
injectedintothebiliaryducts,providingexcellentcontrastonradiographicimages.
Stonesinbileappearasfillingdefectsintheopacifiedducts.Currently,ERCPis
usuallyperformedinconjunctionwithendoscopicretrogradesphincterotomyand
gallstoneextraction. [15]

PercutaneousTranshepaticCholangiography
Percutaneoustranshepaticcholangiography(PTC)maybethemodalityofchoicein
patientsinwhomERCPisdifficult(eg,thosewithpreviousgastricsurgeryordistal
obstructingCBDstone),intheabsenceofanexperiencedendoscopist,andin
patientswithextensiveintrahepaticstonediseaseandcholangiohepatitis.Along
largeboreneedleisadvancedpercutaneouslyandtranshepaticallyintoan
intrahepaticduct,andcholangiographyisperformed.Acathetercanbeplacedin
thebiliarytreeoveraguidewire.
UncorrectedcoagulopathyisacontraindicationforPTC,andthenormalsizeofthe
intrahepaticductsmakestheproceduredifficult.Prophylacticantibioticsare
recommendedtoreducetheriskofcholangitis.
Treatment&Management

ContributorInformationandDisclosures
Author
DouglasMHeuman,MD,FACP,FACG,AGAFChiefofHepatology,HunterHolmesMcGuireDepartmentof
VeteransAffairsMedicalCenterProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,
VirginiaCommonwealthUniversitySchoolofMedicine
DouglasMHeuman,MD,FACP,FACG,AGAFisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofPhysicians,AmericanGastroenterological
Association
Disclosure:Receivedgrant/researchfundsfromNovartisforotherReceivedgrant/researchfundsfromBayerfor
otherReceivedgrant/researchfundsfromOtsukafornoneReceivedgrant/researchfundsfromBristolMyers
SquibbforotherReceivednonefromScynexisfornoneReceivedgrant/researchfundsfromSalixforother
Receivedgrant/researchfundsfromMannKindforother.
Coauthor(s)
JeffAllen,MDAssistantProfessor,DepartmentofSurgery,UniversityofLouisville
Disclosure:Nothingtodisclose.
AnastasiosAMihas,MD,DMSc,FACP,FACGProfessor,DepartmentofMedicine,Divisionof
Gastroenterology,VirginiaCommonwealthUniversitySchoolofMedicineConsultingStaff,Virginia
CommonwealthUniversityHospitalsandClinicsChiefofGIClinicalResearch,DirectorofGIOutpatientService,
AssociateDirectorofHepatology,HunterHolmesMcGuireVeteransAffairsMedicalCenter
AnastasiosAMihas,MD,DMSc,FACP,FACGisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeof
Physicians,AmericanGastroenterologicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,Sigma
Xi,SouthernSocietyforClinicalInvestigation,AmericanFederationforClinicalResearch,Gastroenterology
ResearchGroup
Disclosure:Nothingtodisclose.
ChiefEditor
JulianKatz,MDClinicalProfessorofMedicine,DrexelUniversityCollegeofMedicine
JulianKatz,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanGeriatricsSociety,
AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,AmericanSocietyofLaw,
Medicine&Ethics,AmericanTraumaSociety,AssociationofAmericanMedicalColleges,PhysiciansforSocial
Responsibility
Disclosure:Nothingtodisclose.
Acknowledgements
FirassAbiad,MDHeadofDivision,GeneralandLaparoscopicSurgery,SpecializedMedicalCenterHospital,
SaudiArabia
Disclosure:Nothingtodisclose.
BSAnand,MDProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,BaylorCollegeof
Medicine
BSAnand,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiver
Diseases,AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,andAmerican
SocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
DavidEricBernstein,MDDirectorofHepatology,NorthShoreUniversityHospitalProfessorofClinical
Medicine,AlbertEinsteinCollegeofMedicine
DavidEricBernstein,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyof
LiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,American
GastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.

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BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirector,EmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeof
EmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanThoracic
Society,ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
DavidFMBrown,MDAssociateProfessor,DivisionofEmergencyMedicine,HarvardMedicalSchoolVice
Chair,DepartmentofEmergencyMedicine,MassachusettsGeneralHospital
DavidFMBrown,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
PhysiciansandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
WilliamKChiang,MDAssociateProfessor,DepartmentofEmergencyMedicine,NewYorkUniversitySchool
ofMedicineChiefofService,DepartmentofEmergencyMedicine,BellevueHospitalCenter
WilliamKChiang,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofClinicalToxicology,
AmericanCollegeofMedicalToxicology,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AlfredCuschieri,MD,ChM,FRSE,FRCS,Head,Professor,DepartmentofSurgeryandMolecularOncology,
UniversityofDundee,UK
Disclosure:Nothingtodisclose.
ImadSDandan,MDConsultingSurgeon,DepartmentofSurgery,TraumaSection,ScrippsMemorialHospital
ImadSDandan,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheSurgeryof
Trauma,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanTraumaSociety,California
MedicalAssociation,andSocietyofCriticalCareMedicine
Disclosure:Nothingtodisclose.
DavidGreenwald,MDAssociateProfessorofClinicalMedicine,FellowshipProgramDirector,Departmentof
Medicine,DivisionofGastroenterology,MontefioreMedicalCenter,AlbertEinsteinCollegeofMedicine
DavidGreenwald,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
Gastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanSociety
forGastrointestinalEndoscopy,andNewYorkSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
FayeMaryannLee,MDStaffPhysician,DepartmentofEmergencyMedicine,NewYorkUniversity/Bellevue
HospitalCenter
FayeMaryannLee,MDisamemberofthefollowingmedicalsocieties:PhiBetaKappa
Disclosure:Nothingtodisclose.
SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,Vanderbilt
University
SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AssaadMSoweid,MD,FASGE,FACGAssociateProfessorofClinicalMedicine,Endosonographyand
AdvancedTherapeuticEndoscopy,Director,EndoscopyBronchoscopyUnit,DivisionofGastroenterology,
DepartmentofInternalMedicine,AmericanUniversityofBeirutMedicalCenter,Lebanon
AssaadMSoweid,MD,FASGE,FACGisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Gastroenterology,AmericanCollegeofPhysicians,AmericanCollegeofPhysiciansAmericanSocietyofInternal
Medicine,AmericanGynecologicalandObstetricalSociety,andAmericanMedicalAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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