Gallstone Disease

Gallstone Disease
Nachapan Pengrung , M.D

Gallstone Disease

Definitions
Cholelithiasis = gallstones Acute calculous cholecystitis = 2/2 occlusion of the cystic duct by gallstone leading to gallbladder inflammation Chronic calculous cholecystitis = recurrent episodes of cystic duct obstruction leading to scarring and a nonfunctional gallbladder Chronic acalculous cholecystitis = symptoms of biliary colic, no gallstones, 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 cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct (CHD), causing symptoms of obstructive jaundice

Gallstone Disease

Bile
Bile Bile salts (primary: cholic, chenodeoxycholic acids; secondary: deoxycholic, lithocholic acids) Phospholipids (90% lecithin) Cholesterol Cholesterol solubility depends on the relative concentration of cholesterol, bile salts, and phospholipid

Gallstone Disease

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)

Gallstone Disease

Gallstone Pathogenesis
Pathogenesis of cholesterol gallstones involves: (1) cholesterol supersaturation in bile, (2) crystal nucleation, (3) gallbladder dysmotility, (4) gallbladder absorption Black pigment stones: contain Ca++ salts, a/w hemolytic conditions or cirrhosis, found in the gallbladder Brown pigment stones: Asians, contain Ca++ palmitate, found in bile ducts, a/w biliary dysmotility and bacterial infection

Gallstone Disease

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

Gallstone Disease

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 vascular compromise, stones, impaired immune system, infection w/gas-forming organisms - clostridium, E. coli, Klebsiella) Cholecystoenteric fistula Choledochohlithiasis: 8-15% of pts w/ symptomatic gallstones Cirrhosis Cholangitis Pancreatitis

Gallstone Disease

Symptomatic Gallstones
Provocation/Timing: meals (50%), nighttime Quality: constant Radiation: RUQ to the R scapula (Boas sign) Severity: severe

PE: (+)Murphys sign

Gallstone Disease

RUQ DDx
Gallbladder: cholecystitis, choledocholithiasis, cholangitis Duodenal ulcer Hepatitis Appendicitis (atypical presentation) PNA Pancreatitis

Gallstone Disease

Labs
Order: BMP, amylase/lipase, LFTs, CBC, coags Acute cholecystitis: increased WBC, increased alk phos, slight increase in amylase and T bili

Gallstone Disease

Imaging
KUB - only 15% of gallstones are radiopaque U/S - gallstone identification false(-) rate is 5-15%. It identifies bile 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

Gallstone Disease

Ultrasonographic Images of Three Gallbladders

Strasberg S. N Engl J Med 2008;358:2804-2811

Gallstone Disease

Hepatobiliary Scintigraphy

Strasberg S. N Engl J Med 2008;358:2804-2811

Gallstone Disease

CT Scan of the Abdomen

Thomas L et al. N Engl J Med 1999;341:1134-1138

Gallstone Disease

Diagnostic Criteria for Acute Cholecystitis, According to Tokyo Guidelines

Strasberg S. N Engl J Med 2008;358:2804-2811

Gallstone Disease

Cholecystitis: Management
NPO, IVF, IV antibiotics Non-operative: dissolution therapy ursodeoxycholic acid, chenodeoxycholic acid Operative: cholecystectomy For unstable pts: percutaneous transhepatic cholecystostomy (CT or U/S guided)

Gallstone Disease

Indications for Prophylactic Cholecystectomy

Pediatric gallstones Congenital hemolytic anemia Gallstones >2.5cm Porcelain gallbladder Bariatric surgery Incidental gallstones found during intraabdominal surgery Recommended prior to transplantation

Gallstone Disease

Case 1
HPI: 46y F p/w 4hr h/o nausea and RUQ pain radiating to the R scapula. Symptoms began 1 hr after a fatty meal. 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

Case 1
denotes gallstones denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone

Gallstone Disease

Case 1: Continued
Dx: symptomatic cholethiasis Plan: NPO, IVF, cholecystectomy

Gallstone Disease

Case 2
46y F p/w 4hr h/o nausea and RUQ pain radiating to the R scapula. Symptoms began 1 hr after a fatty meal. Pt currently has no pain. Has had multiple similar episodes. PMHx/PSHx None PE: RUQ minimally TTP, (-)Murphys Labs: WBC 6, LFT normal Studies: RUQ U/S w/cholelithiasis without GB wall thickening or pericholecystic fluid Diagnosis: ?

Gallstone Disease

Case 2: Continued
Dx: chronic calculous cholecystitis Recurrent inflammatory process due to recurrent cystic duct obstruction leading to scarring/wall thickening Treatment: cholecystectomy

Gallstone Disease

Case 3
46yF p/w h/o >24hr of RUQ pain radiating to the R scapula, 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

Case 3: Continued
Curved arrow
Two small stones at GB neck

Straight arrow
Thickened GB wall

pericholecystic fluid = dark lining outside the wall

Gallstone Disease

Case 3: Continued
denotes the GB wall thickening denotes the fluid around the GB

GB also appears distended

Gallstone Disease

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

Case 4
87y M critically ill, on long-term TPN c/o RUQ pain PE: febrile, RUQ TTP U/S: GB wall thickening, pericholecystic fluid, no gallstones What is the diagnosis?

Gallstone Disease

Case 4: Continued
Dx: acute acalculous cholecystitis Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin Risk of: gangrene, empyema, perforation due to ischemia TX: cholecystectomy If pt is too sick, percutaneous cholecystostomy tube followed by cholecystectomy

Gallstone Disease

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

Case 5: Continued
DX: choledocholithiasis Similar presentation as cholelithiasis, except with the addition 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 from ERCP

Gallstone Disease

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

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 transhepatic cholangiogram (PTC)

Gallstone Disease

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

Case 7: Continued
Dx: gallstone pancreatitis 35% of acute pancreatitis secondary 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 Treatment: ABC, resuscitate, NPO/IVF, pain medication ERCP once pancreatitis resolves Cholecystectomy before d/c

Gallstone Disease

Take Home Points

Start with ABCs Cholelithiasis = Female, Fat, Forty, Fertile Stone formation based on the relative concentration of cholesterol, 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