Cholelithiasis (Gallstones) [Gallbladder Disease]
Symptomatic cholelithiasis, choledocholithiasis, biliary colic, and acute cholecystitis are very common with cholelithiasis being found in 10% of the population. The incidence of cholelithiasis increases with age and is more common in women. Other predisposing factors include obesity, pregnancy, diabetes, and chronic hemolytic states.
Evaluation of the Gallbladder.
Laboratory tests including liver function tests, amylase/lipase for evidence of pancreatic involvement. WBC if symptoms acutely present. An elevated alkaline phosphatase is possibly the most sensitive and specific indicator of biliary disease. However, the ALT and AST may become elevated before the alkaline phosphatase.
Plain radiographs may help, since about 15% of stones are radiopaque, but need not be done if other modalities available.
Ultrasonography is generally the initial exam used to evaluate for cholelithiasis. It is used to visualize stones, and evaluate biliary ducts and pancreas. Obesity and overlying abdominal gas decrease the quality of the exam.
Oral cholecystogram is performed by having patient ingest 3 g of iopanoic acid about 12 hours before study. Failure of the gallbladder to opacify indicates gallbladder disease. This test is not reliable in the setting of significant hyperbilirubinemia or acute cholecystitis and has largely been replaced by ultrasonography.
Radionuclide hepatobiliary scan (e.g., HIDA scan) can be used when there is a consideration of acute cholecystitis or biliary outlet obstruction. Failure of gallbladder to visualize when there is the presence of radioisotope in common bile duct 4 hours after injection indicates dysfunction of the gallbladder such as cholecystitis or outlet obstruction (e.g., tumor, choledocholithiasis).
Endoscopic retrograde cholangiopancreatography (ERCP) may also be used to define the anatomy of the biliary tree and may be a better choice than radionuclide scanning in many situations. This is especially true if consideration is being given to laparoscopic surgery and a common duct stone needs to be ruled out.
Biliary Colic. Intermittent obstruction of the cystic duct by gallstones. History will generally include episodes of epigastric and RUQ pain, which may radiate to back. Pain is usually constant, is abrupt in onset, and subsides slowly. Nausea is commonly associated. Attacks may be precipitated by ingestion of fatty foods.
Spasm of the sphincter of Oddi can cause similar symptoms and is more common after cholecystectomy.
Physical exam will reveal absence of fever, possible RUQ or midepigastric tenderness without rebound. Gallbladder may be palpable and the patient may have a positive Murphy’s sign (sudden increase in pain with palpation of RUQ during deep inspiration).
- 95% of those with cholecystitis will have cholelithiasis.
- Presentation is similar to biliary colic (nausea, vomiting, abdominal pain, RUQ tenderness) with the additional features of fever, leukocytosis, mild elevation of bilirubin, elevated alkaline phosphatase. Murphy’s sign may be present.
- Ultrasound only 50% sensitive for cholecystitis. U/S may miss pericholic fluid collections, etc. HIDA scan is diagnostic modality of choice.
- Treatment. Consultation with surgeon is required. Antibiotics are indicated for acute cholecystitis. A third-generation cephalosporin and metronidazole or ampicillin-sulbactam (Unasyn) will cover the most common organisms. There are advantages and disadvantages to early or delayed surgery, though early surgery generally results in lower morbidity and shorter hospitalizations. Surgeon will ultimately need to decide based upon the particular features of the case.
Medical Management of Cholelithiasis.
- Surgical therapy is considered the treatment of choice for cholelithiasis. However, in patients in whom this is not practical, other modalities may be used.
- Cholesterol stones may be dissolved using ursodeoxycholic acid. About 70% of cholesterol stones will respond. However, stones tend to recur when ursodeoxycholic acid is discontinued.
- Lithotripsy can be used to fragment stones, which are then passed spontaneously. ERCP may help with stone removal, and use of ursodeoxycholic acid may prevent recurrence.
- ERCP with sphincterotomy may assist in passing stones.
Gallstones – “cholelithiasis” – chole- means bile and “lith” means stones, “iasis means a condition of”) of varying composition form in the gallbladder, the organ that produces bile. The bile is a product that flows from the liver to the gallbladder. From there it is excreted into the intestines where it combats stomach acid and aids in fat digestion. It is rich in fatty substances, especially cholesterol (extracted from the blood stream by the liver). It also contains bilirubin, a substance formed by the breakdown of hemoglobin from old red blood cells. Sometimes if the balance of these substances is upset, a tiny solid particle forms in the gallbladder. It may grow as more material solidifies around it. A single or multiple stones may be the result.
Symptoms are typically pain (biliary colic) either in the upper right quadrant of the abdomen or between the shoulder blades. The colic is a result of the gallbladder trying unsuccessfuly to empty bile into the intestine. The stone(s) may block the process completely. The conditions are known as cholecystitis and cholelithiasis.
20 million people in the US have them. Women are particularly susceptible.
Workup includes x-ray of the organ, called a cholecystogram and sometimes an ultrasound or CAT scan assists in detecting gallstones if they don’t show up in other tests. Surgical intervention removes the gallbladder. What happens when one no longer has a gallbladder? The bile continues to flow from the liver, but goes directly from the liver to the duodenum.
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