Gallstone Disease
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Transcript of Gallstone Disease
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Gallstones Disease
Gallstone Disease
Tad Kim, M.D.UF Surgery
[email protected](c) 682-3793; (p) 413-3222
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Gallstones Disease
Overview
• Gallstone pathogenesis
• Definitions
• Differential Diagnosis of RUQ pain
• 7 Cases
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Gallstones Disease
Gallstone Pathogenesis
• Bile = bile salts, phospholipids, cholesterol– Also bilirubin which is conjugated b4 excretion
• Gallstones due to imbalance rendering cholesterol & calcium salts insoluble
• Pathogenesis involves 3 stages:– 1. cholesterol supersaturation in bile– 2. crystal nucleation– 3. stone growth
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Gallstones DiseaseDefinitions
Symptomatic cholelithiasis
Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT
Acute cholecystitis
Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrest
Chronic cholecystitis
Recurrent bouts of colic/acute chol’y leading to chronic GB wall inflamm/fibrosis. No fever/WBC.
Acalculous cholecystitis
GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts
Choledocho-lithiasis
Gallstone in the common bile duct (primary means originated there, secondary = from GB)
Cholangitis 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
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Gallstones Disease
Differential Diagnosis of RUQ pain
• Biliary disease– Acute chol’y, chronic chol’y, CBD stone,
cholangitis• Inflamed or perforated duodenal ulcer• Hepatitis• Also need to rule out:
– Appendicitis, renal colic, pneumonia or pleurisy, pancreatitis
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Gallstones Disease
Case 1
• 46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now.
• No prior episodes• Minimal RUQ tenderness, no Murphy’s• WBC 8, LFT normal• RUQ U/S reveals cholelithiasis without GB
wall thickening or pericholecystic fluid• Diagnosis: ?
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Gallstones Disease
Case 1
• → denotes gallstones
• ► denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone
→→
►
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Gallstones Disease
Symptomatic cholelithiasis• aka “biliary colic”• The pain occurs due to a stone obstructing
the cystic duct, causing wall tension; pain resolves when stone passes
• Pain usually lasts 1-5 hrs, rarely > 24hrs• Ultrasound reveals evidence at the crime
scene of the likely etiology: gallstones• Exam, WBC, and LFT normal in this case• Treatment: Laparoscopic cholecystectomy
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Gallstones Disease
Spectrum of Gallstone Disease
• Symptomatic cholelithiasis can be a herald to:– an attack of acute
cholecystitis– or ongoing chronic
cholecystitis
• May also resolve
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Gallstones Disease
Case 2
• Same case, except pt has had multiple prior attacks of similar RUQ pain
• No fever or WBC• Ultrasound reveals gallstones, thickened
GB wall, no pericholecystic fluid
• Diagnosis: ?
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Gallstones Disease
Chronic calculous cholecystitis
• Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones
• Overtime, leads to scarring/wall thickening
• Treatment: laparoscopic cholecystectomy
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Gallstones Disease
Case 3• Same pt, now > 24hrs of RUQ pain
radiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever
• Exam: Palpable, tender gallbladder, guarding, +Murphy’s = inspiratory arrest
• WBC 13, Mild ↑LFT• U/S: gallstones, wall thickening (>4mm),
GB distension, pericholecystic fluid, sonographic Murphy’s sign (very specific)
• Diagnosis: ?
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Gallstones Disease
Case 3
• Curved arrow– Two small stones
at GB neck
• Straight arrow– Thickened GB wall
• ◄ – pericholecystic
fluid = dark lining outside the wall
◄
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Gallstones Disease
Case 3
• → denotes the GB wall thickening
• ► denotes the fluid around the GB
• GB also appears distended
→
►
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Gallstones Disease
Acute calculous cholecystitis
• Persistent cystic duct obstruction leads to GB distension, wall inflammation & edema
• Can lead to: empyema, gangrene, rupture• Pain usu. persists >24hrs & a/w N/V/Fever• Palpable/tender or even visible RUQ mass• Nuclear HIDA scan shows nonfilling of GB
– If U/S non-diagnostic, obtain HIDA• Tx: NPO, IVF, Abx (GNR & enterococcus)• Sg: Cholecystectomy usu within 48hrs
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Gallstones Disease
Case 4
• 87yo M critically ill, on long-term TPN w RUQ pain, fever, ↑WBC
• Ultrasound: GB wall thickening, pericholecystic fluid, no gallstones
• Diagnosis: ?
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Gallstones Disease
Acute acalculous cholecystitis
• In 5-10% of cases of acute cholecystitis• Seen in critically ill pts or prolonged TPN• More likely to progress to gangrene,
empyema, perforation due to ischemia• Caused by gallbladder stasis from lack of
enteral stimulation by cholecystokinin• Tx: Emergent cholecystectomy usu open• If pt is too sick, perc cholecystostomy tube
and interval cholecystectomy later on
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Gallstones Disease
Complications of acute cholecystitisEmpyema of gallbladder
Pus-filled GB due to bacterial proliferation in obstructed GB. Usu. more toxic, high fever
Emphysematous cholecystitis
More commonly in men and diabetics. Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumen
Perforated gallbladder
Occurs in 10% of acute chol’y, usually becomes a contained abscess in RUQ
Less commonly, perforates into adjacent viscus = cholecystoenteric fistula & the stone can cause SBO (gallstone ileus)
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Gallstones Disease
Case 5
• 46yo F p/w RUQ pain, jaundice, acholic stools, dark tea-colored urine, no fevers
• Known history of cholelithiasis• Exam: unremarkable• WBC 8, T.Bili 8, AST/ALT NL, HepB/C neg• Ultrasound: Gallstones, CBD stone,
dilated CBD > 1cm• Diagnosis: ?
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Gallstones Disease
Choledocholithiasis
• Can present similarly to cholelithiasis, except with the addition of jaundice
• DDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with pain
• Tx: Endoscopic retrograde cholangiopancreatography (ERCP)– Stone extraction and sphincterotomy
• Interval cholecystectomy after recovery from ERCP
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Gallstones Disease
Case 6• 46yo F p/w fever, RUQ pain, jaundice
(Charcot’s triad)• If also altered mental status and signs of
shock = Raynaud’s pentad• VS tachycardic, hypotensive• ABC’s, Resuscitate
– 2 large bore IV, Foley, Continuous monitor– 1-2L fluid bolus, repeat until resuscitated
• Diagnosis: ?
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Gallstones Disease
Cholangitis
• Infection of the bile ducts due to CBD obstruction 2ndary to stones, strictures
• Charcot’s triad seen in 70% of pts• May lead to life-threatening sepsis and
septic shock (Raynaud’s pentad)• Tx: NPO, IVF, IV Abx• Emergent decompression via ERCP or
perc transhepatic cholangiogram (PTC)• Used to require emergency laparotomy
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Gallstones Disease
Case 7
• 46yo F p/w persistent epigastric & back pain
• Known history of symptomatic gallstones• No EtOH abuse• Exam: Tender epigastrum• Amylase 2000, ALT 150• Ultrasound: Gallstones• Diagnosis: ?
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Gallstones Disease
Gallstone pancreatitis
• 35% of acute pancreatitis 2ndary 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
• Tx: ABC, resuscitate, NPO/IVF, pain meds• Once pancreatitis resolving, ERCP w stone
extraction/sphincterotomy• Cholecystectomy before hospital discharge
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Gallstones Disease
Take Home Points• As always, ABC & Resuscitate before Dx• Understanding the definitions is key• Is this acute cholecystitis? (fever, WBC, tender on
exam with positive Murphy’s)• Or simply cholelithiasis vs ongoing chronic
cholecystitis? (no fever/WBC)• Is patient sick or toxic-appearing, to suspect
empyema, gangrene or even perforation?• Elicit h/o jaundice, acholic stools, tea-colored urine• Rule out cholangitis, because this will kill the
patient unless dx & tx early