Gallstone Flashcards

Gallstones and Biliary Disease

Asymptomatic Cholelithiasis

• Gallstones in the gallbladder are common (20% of the US population).

• Often discovered incidentally during imaging for other reasons.

• Definition: No symptoms, normal labs, normal physical exam.

• Management: No further management necessary for truly asymptomatic patients because 80% never have any problems.

Symptomatic Cholelithiasis

• Gallstone intermittently and temporarily obstructs the cystic duct, typically after eating fatty foods when hormones released cause gallbladder contraction to release bile and help with fat absorption/digestion.

• Definition: Intermittent pain after eating.

• Symptoms:

  • Intermittent postprandial abdominal pain, typically in the right upper quadrant or epigastric region.

  • Varying frequencies after eating food, classically fatty food, but not always.

  • Normal exam at the time, generally.

• Diagnosis:

  • Ultrasound shows gallstones.

• Treatment:

  • Laparoscopic cholecystectomy is warranted.

  • Can be scheduled electively as an outpatient procedure.

Acute Cholecystitis

• Gallstone gets stuck in the neck of the gallbladder or cystic duct.

• Pressure builds up, leading to stasis and inflammation.

• Symptoms:

  • Right upper quadrant pain (sometimes epigastric pain).

  • Pain lasting for more than four hours is classic.

  • Tenderness in the right upper quadrant.

  • Positive Murphy's sign (pain when taking a deep breath with hand under the ribs in the right upper quadrant).

• Labs:

  • Elevated white blood cell count.

  • Normal bilirubin.

• Ultrasound Findings:

  • Wall thickening.

  • Pericholecystic fluid.

  • Gallstones.

• Treatment:

  • Fluids and antibiotics.

  • Admit to the hospital.

  • Laparoscopic cholecystectomy within 24-48 hours.

Choledocholithiasis

• Gallstone has moved into the common bile duct and is obstructing it.

• Bile cannot leave the liver and backs up into the bloodstream.

• Symptoms:

  • Right upper quadrant pain.

  • Jaundice.

  • Tenderness.

• Labs:

  • Elevated bilirubin is the hallmark of biliary obstruction.

  • White blood cell count might be elevated.

• Ultrasound Findings:

  • Dilated common bile duct and potentially intrahepatic bile ducts.

• Treatment:

  • ERCP (endoscopic retrograde cholangiopancreatography) to clear the bile duct, often with sphincterotomy.

  • Laparoscopic cholecystectomy is indicated after ERCP.

Ascending Cholangitis

• Blockage in the biliary system leads to proliferation of bacteria.

• Serious infection.

• Symptoms:

  • Charcot's Triad: fever, abdominal pain, and jaundice.

  • Reynolds' Pentad: fever, abdominal pain, jaundice, hypotension, and altered mental status.

• Exam:

  • Right upper quadrant tenderness.

  • Jaundice.

  • Signs of sepsis (low blood pressure, tachycardia, fever).

• Labs:

  • Elevated white blood cell count.

  • Elevated bilirubin.

• Ultrasound Findings:

  • Dilated common bile duct and intrahepatic bile ducts.

• Treatment:

  • Follow the tenets of treating shock (antibiotics, fluids).

  • Urgent ERCP for source control.

  • Then, cholecystectomy to prevent further gallstones from obstructing the biliary system. Consider intraoperative cholangiogram to make sure duct is clear.

Gallstone Pancreatitis

• Gallstone blocks both the common bile duct and the pancreatic duct at the ampulla of Vater.

• Leads to inflammation of the pancreas.

• Symptoms:

  • Epigastric pain radiating to the back (classic pancreatitis symptom).

• Exam:

  • Tender in epigastrum.

• Labs:

  • Elevated lipase.

  • White blood cell count may be elevated.

  • Bilirubin may be elevated if the stone is still obstructing the common bile duct or may be normalized if the stone has passed.

• Imaging:

  • Dilated common bile duct or intrahepatic bile ducts (depending on whether the stone is still obstructing).

  • CT scan shows inflammation around the pancreas.

• Treatment:

  • Address the pancreatitis with fluids, bowel rest, and pain control.

  • Cholecystectomy during the same admission or shortly after discharge to prevent recurrent episodes.

Passed Stone

• Patients present initially with symptoms of choledocholithiasis or gallstone pancreatitis.

• Bilirubin is initially elevated but drops quickly without intervention.

• Imaging or ERCP may not find a stone.