Gallbladder Disease

   

Cholecystitis Cholelithiasis Choledocholithiasis Cholangitis Gallstone pancreatitis Gallstone ileus:
Occluded cystic duct
 - RUQ pain and tender,
  +/-fever
  +/-WBC
*(+) Murphy sign: cessation of inspiration
Gallstone inside GB

- Asymptomatic stones
- Do NOT recommend prophylactic surgery
Charcot’s triad:
- fever, abd pain, and jaundice

Reynolds' pentad
:
- Charcot’s + confusion + shock
  Obstructed ampulla of Vater
- Reflux of bile
Biliary-enteric fistula
6/1000 SBO

Background

  • Biliary colic is an abdominal pain Sx related to dilation of the cystic duct, irritation of gallbladder, and associated viscera
    • Majority of cases d/t gallstones composed of cholesterol salts
  • Biliary colic often preceding Sx of other dz of biliary tract; considered part of spectrum of dz w/ significant mortality/morbidity
  • Goals of diagnosis
    • Rule out more serious abdominal pathology
    • Control Sx
    • Obtain surgical referral

Pathophysiology

  • Mechanism
    • Gallstones or sludge create a mechanical obstruction of the cystic or common bile duct leading to irritation, spasms, and pain
    • Rarely, biliary colic may occur in the absence of gallstones (acalculous biliary colic)
      • Poorly understood; may be result of sphincter of Oddi dysfunction, bile stasis, or gallbladder dyskinesia
         
  • Etiology/Risk Factors
    • Gallstones, bile stasis, gallbladder dysfunction
    • Risk factors generally same as for gallstones
      • Increasing age
      • Female
      • Obesity; recent weight loss
      • Pregnancy
      • Hispanic, Native American, and Northern European descent
      • Hormone replacement therapy
      • Family history
         
  • Epidemiology
    • Incidence/Prevalence
      • Gallbladder dz is common; symptomatic gallstones leading cause of cholecystectomy in developed world
      • 12% of pop has gallstone dz, 60-80% will become symptomatic
    • Morbidity/Mortality
      • 10% w/ symptomatic gallstones will develop acute cholecystitis

Diagnostics

  • History/Symptoms
    • Epigastric or RUQ pain, generally “dull” and “constant” in nature
    • Assoc w/ eating, often with fatty meals
    • Lasting minutes to hours
    • May have referral of pain to chest, back, or shoulder
    • Nausea/vomiting common, diarrhea
    • Generally no fevers or chills (should prompt suspicion for more serious abdominal pathology)
    • Charcot's triad
      • Pain, fever, jaundice
    • Reynold's pentad
      • Pain, fever, jaundice, altered mental status, hypotension
         
  • Physical Exam/Signs
    • General, Vitals: fever, ill-appearance, guarded w/o signs of peritonitis (signs of peritonitis include rebound tenderness)
      • Murphy's sign: inspiratory pause w/ deep palpation of RUQ
    • Abd/GI/GU
      • Abdominal tenderness, worse in epigastric region, and RUQ
      • Older, diabetic, or spinal cord injury patients may have only diffuse, nonspecific tenderness
         
  • Labs/Tests
    • Labs will generally be normal in uncomplicated biliary colic
    • CBC +Diff, CMP
    • Amylase (Lipase)
    • Urinalysis
    • Urine hCG (pregnancy test)
    • If toxic or jaundiced
      • +/- Lactate, Coags, Direct Bilirubin
         
  • Imaging
    • Abd U/S
      • 95% sensitive for gallstones (esp. RUQ)
      • Stones/sludge common
      • Severe pathology: thickened gallbladder wall (> 4 mm), distended gallbladder, or pericholecystic fluid
      • Bedside U/S performed by ED physician is ~92% sensitive for cholelithiasis
    • Upright Chest X-Ray
      • Free air, 10-20% gallstones visible on X-ray
    • CT scan of abdomen and pelvis not a good screening test for uncomplicated biliary colic
    • HIDA scan (cholescintigraphy)
    • ERCP/MRCP/EUS
       
  • Other Tests/Criteria
  • Differential Diagnosis
    • Cholecystitis, Cholangitis
    • Choledocholithiasis
    • Pancreatitis
    • GERD, Gastritis
    • Perforated hollow viscous
    • PUD
    • Renal colic
    • Right lower lobe pneumonia
    • Musculoskeletal pathology
    • Appendicitis
    • Fitz-Hugh-Curtis syndrome
    • Amebic liver dz

Treatment

  1. Initial/Prep
    • ABCs, IV fluids, O2, Monitors
    • Goal is supportive care
      • Analgesia for pain
      • Antiemetics for nausea
      • Abx if infxns
         
  2. Medical/Pharmaceutical
    • NSAIDs
      • As efficacious as opiates
      • Toradol
      • Ibuprofen
      • Diclofenac
    • Opiates
      • May interfere w/ HIDA scan, can cause nausea
      • Morphine
      • Oxycodone
      • Tramadol
    • Antiemetics
      • Ondansetron
      • Promethazine
      • Metoclopramide
      • Compazine
    • Antibiotics if bacterial infxn suspected
       
  3. Surgical/Procedural
    • Cholecystectomy is standard Tx for symptomatic gallstones
    • Asymptomatic gallstones are generally not treated w/ surgery
    • ERCP may be preferred in certain patients w/ other risk factors
    • Lithotripsy
       
  4. Prevention
    • Lifestyle changes
      • Dietary modification (low fat)
      • Slow, appropriate weight loss
    • Prophylaxis: ursodeoxycholic acid
      • Expensive
      • May takes months-years to work
      • May prevent new stone formation and possibly dissolve formed stones
      • Only for cholesterol stones

Disposition

  1. Uncomplicated biliary colic outpatient care
    • Analgesia, antiemetics, a low fat diet, and follow-up
  2. Admit if
    • Abnormal vital signs, signs of serious infxn, or an inability to control Sx
  3. Surgical consult indicated for more serious hepato-biliary dz
  4. GI consult appropriate for certain patients
  5. Outpatient follow-up if gallstones but asymptomatic