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Gallstone Disease

Gallstone Disease. Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222. Overview. Gallstone pathogenesis Definitions Differential Diagnosis of RUQ pain 7 Cases. Gallstone Pathogenesis. Bile = bile salts, phospholipids, cholesterol

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Gallstone Disease

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  1. Gallstone Disease Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222

  2. Overview • Gallstone pathogenesis • Definitions • Differential Diagnosis of RUQ pain • 7 Cases

  3. 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

  4. Definitions

  5. 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

  6. 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: ?

  7. Case 1 • → denotes gallstones • ► denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone → → ►

  8. 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

  9. Spectrum of Gallstone Disease • Symptomatic cholelithiasis can be a herald to: • an attack of acute cholecystitis • or ongoing chronic cholecystitis • May also resolve

  10. 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: ?

  11. 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

  12. 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: ?

  13. Case 3 • Curved arrow • Two small stones at GB neck • Straight arrow • Thickened GB wall • ◄ • pericholecystic fluid = dark lining outside the wall ◄

  14. Case 3 • → denotes the GB wall thickening • ► denotes the fluid around the GB • GB also appears distended → ►

  15. 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

  16. Case 4 • 87yo M critically ill, on long-term TPN w RUQ pain, fever, ↑WBC • Ultrasound: GB wall thickening, pericholecystic fluid, no gallstones • Diagnosis: ?

  17. 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

  18. Complications of acute cholecystitis

  19. 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: ?

  20. 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

  21. 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: ?

  22. 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

  23. 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: ?

  24. 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

  25. 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

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