Gallstone Disease
last authored: Aug 2009, David LaPierre
Introduction
Gallstones, usually formed from precipitated cholestrol, affect perhaps one-fifth of the adult population, though most are asymptomatic. However, gallstones can cause extreme pain and have other serious impacts, including:
- cholelithiasis
- cholecystitis - gallbladder inflammation/infection
- choledocolithiasis - common bile duct obstruction
- cholangitis - common bile duct inflammation/infection
Most of the 10-15% of adults with gallstones have no symptoms, with only 1-3% of people developing pain or other symptoms. As many as 40% of people with general anaesthesia and surgery with asymptomatic gallstones can become symptomatic within 6 weeks.
Obstruction of the biliary tract can occur in the cystic duct, common hepatic duct, common bile duct, and ampulla of Vater.
Contraction of the gallbladder during transient cystic obstruction can cause biliary colic. Persistent obstruction of the cystic duct leads to superimposed inflammation or infection (acute cholecystitis). Distal duct obstruction can lead to abdominal pain, cholangitis, or pancreatitis.
The Case of...
Causes and Risk Factors
Causes of gallstones include:
cholesterol supersaturation: estrogens, mulitparity, oral contraceptives, obesity, rapid weight loss, and terminal ileal disease
nucleating factors: biliary pathogens, antibiotics such as ceftriaxone; TPN and blood transfusions also promote bile pigment accumulation
gallbladder hypomotility: pregnancy, somatostatin, fasting, bile duct strictures, choledochal cysts, biliary parasites, TPN
Pathophysiology
Typically associated with mechanical obstruction of the cystic duct and increasing lumenal pain from wall distension.
Cholecystitis leads to ischemia and bacterial invasion.
Pigment stones can form from hemolysis, ethanol, or bacteria.
Increasing peritoneal involvement leads to localization of pain. Murphy's sign is not specific, however, as localized pressure can
The bacteria most involved include:
Gallstones are of two types - cholesterol (75%) and pigmented (brown or black - 25%). The latter is composed of calcium bilirubinate and other calcium salts.
Cholesterol stones form in the context of cholesterol supersaturation which occurs in most people. In some cases, nucleation occurs and stones begin. Factors which predispose for gallstones include bile transit time, gallbladder hypomotility, bile composition and relative concentrations, and nucleating agents such as bacteria, mucin, and glycoproteins.
Pigment stones are associated with increased production of bilirubin conjugates (through hemolytic states), increased biliary calcium and bicarbonate, cirrhosis, and bacterial deconjugation of bilirubin.
Acute cholecystitis refers to distension, edema, ischemia, inflammation, and secondary infection of the gallbladder, generally following cystic duct obstruction by gallstones or less commonly by cancer or sludge.
Signs and Symptoms
About one half of all people remain asymptomatic, one third develop biliary colic or chronic cholecystitis, and 15% develop acute complications.
- history
- physical exam
History
Biliary colic is typically a steady ache in the epigastrium or right upper quadrant, has sudden onset, reaches a plateau in a few minutes, and subsides gradually over minutes to hours. Referred pain can be to the scapula or right shoulder. Nausea and vomiting may occur.
Acute cholecystitis is characterized by acute pain that gradually increases, with radiation to the right lumber, scapular, and shoulder area. Nausea, vomiting, anorexia, andlow-grade fever are common. Unlike biliary pain, the pain does not subside spontaneously. RUQ palpation can lead to inspiratory arrest, called Murphy's sign.
Acute cholangitis is classically mainfest by abdominal pain, jaundice, and fever.
Steady pain
visceral pain, can be present in many places.
tends to diffuse after 30 min-few hours
Associated nausea and vomiting
Physical Exam
Jaundice suggests biliary tree blockage.
RUQ tenderness, guarding, or rigidity can be present, especially on inspiration (Murphy's sign)
fever and tachycardia can be present, suggesting cholecystitis or cholangitis
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
CBC: increased WBC
ESR or CRP
liver enzymes:
- isolated increased transaminases can be do to the field effect of inflammation
- increased transaminases, Alk Phos, and GGT suggest choledocolithiasis
Bilirubin, alkaline phosphatase, and GGT
Markers of pancreatitis suggests ductal blockade
Cholestasis causes serum alkaline phosphatase levels to rise as a result of retention of bile acids in the liver, solubilizing alkaline phosphatase off the hepatocyte plasma membrane and stimulating its synthesis.
5'-nucleotidase, γ-glutamyl transpeptidase, and other plasma membrane enzymes are similarly released into the circulation during bile duct obstruction or cholestasis.
Diagnostic Imaging
Ultrasound (98% sensitivity) can be used to look for:
- gallstones
- pericholecystic fluid
- thick-walled gallbladder
- ductal distension
- sonographic Murphy's sign
Gallstones are best imaged using transabdominal ultrasonography, though accuracy is about 20% for stones in the common bile duct. Endoscopic ultrasound or magnetic resonance cholangiopancreatography are useful for revealing these stones.
Bile duct dilation suggests common ductal problems. A normal duct is 6-8mm.
HAIDA scan is useful with strong clinical suspicion but a negative ultrasound. Absence of gallbladder filling strongly suggests obstruction.
ERCP can be very helpful, but have a mortality rate of 0.8%.
MRCP is much less invasive.
Abdominal X-ray: 80% of gallstones are radiolucent and so will not picked up on X-ray
Ultrasound:
Ductal thickening
Differential Diagnosis
Gallbladder polyps suggest lithogenic bile and microcholethithiasis
Gallbladder adenomas and carcinomas.
Treatments
Cholangitis should be treated according to ABC's
Ciprofloxacin, ceftriaxone often used.
ERCP is need be.
Surgery
Transhepatic, radiographic-guided ductal decompression can be done.
Pain control
opioids are often used
Adjuvants
anti-emetics, such as dimenhydramine
Stone-dissolving, such as medications or
Surgery
If gallstones are evident by clinical exam and imaging, a laproscopic excision of the gallbladder should be done as soon as is possible.
If surgery is not possible, a percutaneous drain - a cholecystostomy tube - can be used to relieve pressure from the gallbladder.
Asymptomatic people should be followed expectantly.
Prophylactic cholecystectomy is considered in people with increased risk of complications:
- diabetes
- calcified (porcelain) gallbladder, or large polyps, both an increased risk for carcinoma
- sickle cell anemia
- children with gallstones due to frequent symptomatic disease
- Native Americans, who are at increased risk of developing cancer if gallstones are present.
Laparoscopic cholecystectomy can be accompanied by ERCP is choledocholithiasis is suspected.
Consequences and Course
A patient with resolving biliary pain has a 50% likelihood of recurrence within one year.
Bile leak can follow surgery, and is characterized by pain in recovery room and worsening pain. These should be treated by a percutaneous drain, followed by ERCP and sphincterotomy.
acute cholecystitis can result, as can gallstone ileus and gallbladder cancer.
The Case of...
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