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  1. 1. Gallstone Disease
  2. 2. Overview <ul><li>Gallstone pathogenesis </li></ul><ul><li>Definitions </li></ul><ul><li>Differential Diagnosis of RUQ pain </li></ul><ul><li>7 Cases </li></ul>
  3. 3. Gallstone Pathogenesis <ul><li>Bile = bile salts, phospholipids, cholesterol </li></ul><ul><ul><li>Also bilirubin which is conjugated b4 excretion </li></ul></ul><ul><li>Gallstones due to imbalance rendering cholesterol & calcium salts insoluble </li></ul><ul><li>Pathogenesis involves 3 stages: </li></ul><ul><ul><li>1. cholesterol supersaturation in bile </li></ul></ul><ul><ul><li>2. crystal nucleation </li></ul></ul><ul><ul><li>3. stone growth </li></ul></ul>
  4. 4. Definitions Infection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic shock Cholangitis Gallstone in the common bile duct (primary means originated there, secondary = from GB) Choledocho-lithiasis GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts Acalculous cholecystitis Recurrent bouts of colic/acute chol’y leading to chronic GB wall inflamm/fibrosis. No fever/WBC. Chronic cholecystitis Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrest Acute cholecystitis Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT Symptomatic cholelithiasis
  5. 5. Differential Diagnosis of RUQ pain <ul><li>Biliary disease </li></ul><ul><ul><li>Acute chol’y, chronic chol’y, CBD stone, cholangitis </li></ul></ul><ul><li>Inflamed or perforated duodenal ulcer </li></ul><ul><li>Hepatitis </li></ul><ul><li>Also need to rule out: </li></ul><ul><ul><li>Appendicitis, renal colic, pneumonia or pleurisy, pancreatitis </li></ul></ul>
  6. 6. Case 1 <ul><li>46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now. </li></ul><ul><li>No prior episodes </li></ul><ul><li>Minimal RUQ tenderness, no Murphy’s </li></ul><ul><li>WBC 8, LFT normal </li></ul><ul><li>RUQ U/S reveals cholelithiasis without GB wall thickening or pericholecystic fluid </li></ul><ul><li>Diagnosis: ? </li></ul>
  7. 7. Case 1 <ul><li>-> denotes gallstones </li></ul><ul><li>► denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone </li></ul>-> -> ►
  8. 8. Symptomatic cholelithiasis <ul><li>aka “biliary colic” </li></ul><ul><li>The pain occurs due to a stone obstructing the cystic duct, causing wall tension; pain resolves when stone passes </li></ul><ul><li>Pain usually lasts 1-5 hrs, rarely > 24hrs </li></ul><ul><li>Ultrasound reveals evidence at the crime scene of the likely etiology: gallstones </li></ul><ul><li>Exam, WBC, and LFT normal in this case </li></ul><ul><li>Treatment: Laparoscopic cholecystectomy </li></ul>
  9. 9. Spectrum of Gallstone Disease <ul><li>Symptomatic cholelithiasis can be a herald to: </li></ul><ul><ul><li>an attack of acute cholecystitis </li></ul></ul><ul><ul><li>or ongoing chronic cholecystitis </li></ul></ul><ul><li>May also resolve </li></ul>Cholelithiasis Asymptomatic cholelithiasis Symptomatic cholelithiasis Chronic calculous cholecystitis Acute calculous cholecystitis
  10. 10. Case 2 <ul><li>Same case, except pt has had multiple prior attacks of similar RUQ pain </li></ul><ul><li>No fever or WBC </li></ul><ul><li>Ultrasound reveals gallstones, thickened GB wall, no pericholecystic fluid </li></ul><ul><li>Diagnosis: ? </li></ul>
  11. 11. Chronic calculous cholecystitis <ul><li>Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones </li></ul><ul><li>Overtime, leads to scarring/wall thickening </li></ul><ul><li>Treatment: laparoscopic cholecystectomy </li></ul>
  12. 12. Case 3 <ul><li>Same pt, now > 24hrs of RUQ pain radiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever </li></ul><ul><li>Exam: Palpable, tender gallbladder, guarding, +Murphy’s = inspiratory arrest </li></ul><ul><li>WBC 13, Mild ↑LFT </li></ul><ul><li>U/S: gallstones, wall thickening (>4mm), GB distension, pericholecystic fluid, sonographic Murphy’s sign (very specific) </li></ul><ul><li>Diagnosis: ? </li></ul>
  13. 13. Case 3 <ul><li>Curved arrow </li></ul><ul><ul><li>Two small stones at GB neck </li></ul></ul><ul><li>Straight arrow </li></ul><ul><ul><li>Thickened GB wall </li></ul></ul><ul><li>◄ </li></ul><ul><ul><li>pericholecystic fluid = dark lining outside the wall </li></ul></ul>◄
  14. 14. Case 3 <ul><li>-> denotes the GB wall thickening </li></ul><ul><li>► denotes the fluid around the GB </li></ul><ul><li>GB also appears distended </li></ul>-> ►
  15. 15. Acute calculous cholecystitis <ul><li>Persistent cystic duct obstruction leads to GB distension, wall inflammation & edema </li></ul><ul><li>Can lead to: empyema, gangrene, rupture </li></ul><ul><li>Pain usu. persists >24hrs & a/w N/V/Fever </li></ul><ul><li>Palpable/tender or even visible RUQ mass </li></ul><ul><li>Nuclear HIDA scan shows nonfilling of GB </li></ul><ul><ul><li>If U/S non-diagnostic, obtain HIDA </li></ul></ul><ul><li>Tx : NPO, IVF, Abx (GNR & enterococcus) </li></ul><ul><li>Sg: Cholecystectomy usu within 48hrs </li></ul>
  16. 16. Case 4 <ul><li>87yo M critically ill, on long-term TPN w RUQ pain, fever, ↑WBC </li></ul><ul><li>Ultrasound: GB wall thickening, pericholecystic fluid, no gallstones </li></ul><ul><li>Diagnosis: ? </li></ul>
  17. 17. Acute acalculous cholecystitis <ul><li>In 5-10% of cases of acute cholecystitis </li></ul><ul><li>Seen in critically ill pts or prolonged TPN </li></ul><ul><li>More likely to progress to gangrene, empyema, perforation due to ischemia </li></ul><ul><li>Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin </li></ul><ul><li>Tx : Emergent cholecystectomy usu open </li></ul><ul><li>If pt is too sick, perc cholecystostomy tube and interval cholecystectomy later on </li></ul>
  18. 18. Complications of acute cholecystitis Less commonly, perforates into adjacent viscus = cholecystoenteric fistula & the stone can cause SBO ( gallstone ileus ) Occurs in 10% of acute chol’y, usually becomes a contained abscess in RUQ Perforated gallbladder More commonly in men and diabetics. Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumen Emphysematous cholecystitis Pus-filled GB due to bacterial proliferation in obstructed GB. Usu. more toxic, high fever Empyema of gallbladder
  19. 19. Case 5 <ul><li>46yo F p/w RUQ pain, jaundice, acholic stools, dark tea-colored urine, no fevers </li></ul><ul><li>Known history of cholelithiasis </li></ul><ul><li>Exam: unremarkable </li></ul><ul><li>WBC 8, T.Bili 8, AST/ALT NL, HepB/C neg </li></ul><ul><li>Ultrasound: Gallstones, CBD stone, dilated CBD > 1cm </li></ul><ul><li>Diagnosis: ? </li></ul>
  20. 20. Choledocholithiasis <ul><li>Can present similarly to cholelithiasis, except with the addition of jaundice </li></ul><ul><li>DDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with pain </li></ul><ul><li>Tx : Endoscopic retrograde cholangiopancreatography (ERCP) </li></ul><ul><ul><li>Stone extraction and sphincterotomy </li></ul></ul><ul><li>Interval cholecystectomy after recovery from ERCP </li></ul>
  21. 21. Case 6 <ul><li>46yo F p/w fever, RUQ pain, jaundice ( Charcot’s triad ) </li></ul><ul><li>If also altered mental status and signs of shock = Raynaud’s pentad </li></ul><ul><li>VS tachycardic, hypotensive </li></ul><ul><li>ABC’s, Resuscitate </li></ul><ul><ul><li>2 large bore IV, Foley, Continuous monitor </li></ul></ul><ul><ul><li>1-2L fluid bolus, repeat until resuscitated </li></ul></ul><ul><li>Diagnosis: ? </li></ul>
  22. 22. Cholangitis <ul><li>Infection of the bile ducts due to CBD obstruction 2ndary to stones, strictures </li></ul><ul><li>Charcot’s triad seen in 70% of pts </li></ul><ul><li>May lead to life-threatening sepsis and septic shock ( Raynaud’s pentad ) </li></ul><ul><li>Tx : NPO, IVF, IV Abx </li></ul><ul><li>Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC) </li></ul><ul><li>Used to require emergency laparotomy </li></ul>
  23. 23. Case 7 <ul><li>46yo F p/w persistent epigastric & back pain </li></ul><ul><li>Known history of symptomatic gallstones </li></ul><ul><li>No EtOH abuse </li></ul><ul><li>Exam: Tender epigastrum </li></ul><ul><li>Amylase 2000, ALT 150 </li></ul><ul><li>Ultrasound: Gallstones </li></ul><ul><li>Diagnosis: ? </li></ul>
  24. 24. Gallstone pancreatitis <ul><li>35% of acute pancreatitis 2ndary to stones </li></ul><ul><li>Pathophysiology </li></ul><ul><ul><li>Reflux of bile into pancreatic duct and/or obstruction of ampulla by stone </li></ul></ul><ul><li>ALT > 150 (3-fold elevation) has 95% PPV for diagnosing gallstone pancreatitis </li></ul><ul><li>Tx : ABC, resuscitate, NPO/IVF, pain meds </li></ul><ul><li>Once pancreatitis resolving, ERCP w stone extraction/sphincterotomy </li></ul><ul><li>Cholecystectomy before hospital discharge </li></ul>
  25. 25. Take Home Points <ul><li>As always, ABC & Resuscitate before Dx </li></ul><ul><li>Understanding the definitions is key </li></ul><ul><li>Is this acute cholecystitis? (fever, WBC, tender on exam with positive Murphy’s) </li></ul><ul><li>Or simply cholelithiasis vs ongoing chronic cholecystitis? (no fever/WBC) </li></ul><ul><li>Is patient sick or toxic-appearing, to suspect empyema, gangrene or even perforation? </li></ul><ul><li>Elicit h/o jaundice, acholic stools, tea-colored urine </li></ul><ul><li>Rule out cholangitis, because this will kill the patient unless dx & tx early </li></ul>