What is Cholelithiasis ?
1 or more calculi (gallstones) in the gallbladder
Risk Factors: Cholelithiasis
Female gender Fat Forty Fertile Native Indian ethnicity Western diet (+) FH
Pathophysiology : Cholelithiasis
Cholesterol stones account for 85% of gallstones
Form from bile that’s supersaturated (sludge) w/cholesterol produced by liver
Crystals or “microstones” are formed, then form into larger stones
Stone may be “silent” or become lodged in cystic duct or CBD, causing pain & cholecystitis
Stones can fill the entire gallbladder
Cholelithiasis : Black pigment stones
- Small & hard
A. Ca bilirubinate & inorganic Ca salts
B. Form w/alcoholic liver disease, chronic hemolysis, & older age
Cholelithiasis :
Brown pigment stones
- Soft & greasy
A. Bilirubinate & fatty acids
B. Form during infection, inflammation, and parasitic infestation
Signs & Symptoms : Cholelithiasis
- 80% asymptomatic
- +/- N/V
- Biliary colic
A. Most common
B. Sudden onset RUQ pain w/radiation to back or right shoulder/arm, ↑ intensity w/in 15-60 min, steady intensity (not colicky) up to 12 h (usually < 6 h), then gradually disappears over 30-90 min, leaving dull ache
Diagnostic Studies : Cholelithiasis
- Ultrasonography
A. Method of choice for detecting gallstones
B. 95% sensitivity & specificity - Cholescintigraphy (HIDA scan w/EF)
A. If needed
Prognosis : Cholelithiasis
Once biliary symptoms begin, they’re likely to recur
Pain returns in 20-40% of patients/year
1-2% of patients/yr develop complications
- Cholecystitis
- Choledocholithiasis
- Cholangitis
- Gallstone pancreatitis
Treatment : Cholelithiasis
- Cholecystectomy for symptomatic stones
A. Laparoscopic or open laparotomy
Surgical Landmarks : What is Calot’s Triangle?
- Cystic Duct
- Common Hepatic Duct
- Margin of Liver
Surgical Landmarks: What is Mascagni’s (Lund’s) Lymph Node?
- Sentinel lymph node of the gallbladder
2. ↑ in size incholecystitis& cholangitis
Treatment : Cholelithiasis
- Stone dissolution
A. Gallstones dissolved by oral bile acids over months
B. Candidates
- Pt who declines surgery
- High surgical risk
- Small, radiolucent stones (likely cholesterol)
C. Ursodeoxycholic acid (Ursodiol) 8-10 mg/kg/day po
-Dissolves 80% of tiny stones (< 0.5 cm) w/in 6 mo
What is Acute Cholecystitis ?
- Inflammation of gallbladder 2° to gallstone obstructing cystic duct
A. Develops over hours - Most common complication of cholelithiasis
- 95% of patients w/acute cholecystitis have cholelithiasis
Signs & Symptoms : Acute Cholecystitis
- Similar to biliary colic but lasts longer & more severe
- Vomiting is common
- Fever (low grade)
- Right subcostal tenderness
- (+) Murphy’s sign
- Guarding
Sx’s begin to subside in 2-3 days & resolve w/in 1 wk in 85% of patients
Signs & Symptoms in Elderly: Acute Cholecystitis
- Anorexia
- Vomiting
- Malaise
- Weakness
- +/- fever
Complications : Acute Cholecystitis
- 10% perforate
A. Peritonitis - ↑ pain, high fever, rigors, & rebound tenderness or ileus suggest:
A. Empyema (pus in the gallbladder)
B. Gangrene
C. Perforation - When sx’s accompanied by jaundice, CBD obstruction is likely
A. Due to stones or inflammation - Mirizzi’s syndrome
A. Rare
B. Gallstone impacted in cystic duct or Hartman’s pouch, compresses & obstructs CBD → cholestasis (jaundice) - Gallstone pancreatitis
A. Gallstones pass from gallbladder into CBD block pancreatic duct - Cholecystoenteric fistula
A. Rare
B. Large stone erodes thru gallbladder wall, creating a fistula into small bowel
Diagnostic Studies : Acute Cholecystitis
- Labs
A. Leukocytosis w/ L shift
B. Bilirubin up to 4 mg/dL & mildly elevated alkaline phos - Ultrasonography
A. Best test to detect gallstones
B. Pericholecystic fluid or thickening of the GB wall → acute inflammation - Cholescintigraphy (HIDA scan)
A. If USN results are equivocal or (-) & ↑ suspicion
B. Failure of the radionuclide to fill GB → obstructed cystic duct
C. Low EF → GB dysfunction
Treatment : Acute Cholecystitis
- Hospital admission, IV fluids, & analgesia w/ketorolac (Toradal) or opioid
- NPO
- NG tube to suction if vomiting or ileus present
- IV antibiotics for possible infection
A. Empiric Tx [gram (-) enteric organisms]
- IV ceftriaxone (Rocephin) 2 g q 24h
+
-IV Metronidazole (Flagyl) 500 mg q 8h
OR
-IV piperacillin/tazobactam (Zosyn) 4 g q 6h alone - Cholecystectomy
A. Early cholecystectomy preferred
- In 1st 24-48 h IF:
(Dx clear & low surgical risk,
Elderly or diabetic & higher risk of infectious complications,
Empyema, gangrene, perforation, or acalculous cholecystitis)
What is Cholangitis ?
- CBD blocked & infection occurs backing up into the liver
A. Can block the hepatic or common bile ducts & force bile into the circulation → jaundice - MEDICAL EMERGENCY
- Defined by “CHARCOT’S TRIAD”
A. RUQ pain
B. Fever
C. Jaundice
Pathophysiology : Cholangitis
- Choledocholithiasis
- Biliary tract manipulations/interventions & stents more common cause
- Hepatobiliary malignancies less common cause
- Most common anaerobic organism- Bacteroides fragilis
Diagnostic Studies : Cholangitis
- Ultrasonography
- CBC w/diff
A. Leukocytosis w/L shift - LFT’s
A. Hyperbilirubinemia
B. ↑ alkaline phos - Blood cultures
Treatment : Cholangitis
- IV antibiotic therapy
A. IV ceftriaxone (Rocephin) 2 g q 24h Gm (-)
+
B. IV metronidazole (Flagyl) 500 mg q 8h anearobes
+
C. IV ampicillin 4 g q 6h Gm (+)
OR
D. IV Fluoroquinolone (Cipro or Levaquin) - If severe or toxic cholangitis
A. May require emergency biliary drainage - Diagnostic & therapeutic purposes (drainage)
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Percutaneous transhepatic cholangiography (PTC)
A. Needle inserted through skin at R subcostal area, guide-wire passed through liver & into the blockage in the bile duct
B. Stent placed - Eventual cholecystectomy if candidate
Chronic Cholecystitis : Characteristics
- Long-standing gallbladder inflammation almost always due to gallstones
- Damage ranges from modest chronic inflammatory cells to a fibrotic, shrunken gallbladder
- Extensive calcification due to fibrosis is called porcelain gallbladder
Signs & Symptoms : Chronic Cholecystitis
- Gallstones intermittently obstruct cystic duct causing recurrent biliary colic
- Generally mild sx’s
- RUQ tenderness may be present, but no fever
- Fever suggests acute cholecystitis
- Once episodes begin, they are likely to recur
