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
Disease

Definitions
Symptomatic
cholelithiasis

Wax/waning postprandial epigastric/RUQ pain

due to transient cystic duct obstruction by stone,
no fever/WBC, normal LFT

Acute
cholecystitis
Chronic
cholecystitis

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.

Acalculous
cholecystitis

GB inflammation due to biliary stasis(5% of time)

and not stones(95%). Seen in critically ill pts

Choledocholithiasis

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 choly, chronic choly, 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 Murphys
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

Symptomatic
cholelithiasis can
be a herald to:

Cholelithiasis

Asymptomatic
cholelithiasis

Symptomatic
cholelithiasis

an attack of acute
cholecystitis
or ongoing chronic
cholecystitis

May also resolve

Chronic
calculous
cholecystitis

Acute
calculous
cholecystitis

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, +Murphys = inspiratory arrest
WBC 13, Mild LFT
U/S: gallstones, wall thickening (>4mm),
GB distension, pericholecystic fluid,
sonographic Murphys 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 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)

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
(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: ?

Gallstones
Disease

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

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 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