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Gallstone Disease
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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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Strasberg S. N Engl J Med 2008;358:2804-2811
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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Strasberg S. N Engl J Med 2008;358:2804-2811
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
What is the diagnosis?
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
What is the diagnosis?
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
What is the diagnosis?
Gallstone Disease
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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
Gallstone Disease
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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 diagnosis?
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)
Gallstone Disease
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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 diagnosis?
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
Gallstone Disease
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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