Symptomatic cholelithiasis

Background

• While a significant portion of the population have asymptomatic gallstones, symptomatic cholelithiasis refers to pain caused by intermittent obstruction of the cystic duct by a stone

Anatomy & Pathophysiology

• Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
• These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
• Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

Gallbladder disease types

Gallbladder anatomy (overview).

Gallbladder anatomy

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.

• Symptomatic cholelithiasis (biliary colic)
• Choledocholithiasis
• Acute calculous cholecystitis
• Ascending cholangitis
• Acalculous cholecystitis
• Biliary atresia
• Cholestasis of pregnancy

Clinical Features

History

• RUQ pain or epigastric pain, often postprandial and constant, lasting 1-5hrs and then remits
  • "Colic" can be a misnomer, as biliary colic is often described by patients as constant
  • May radiate to the right upper back; radiation to the right shoulder increases likelihood, but is not sensitive
  • Pain >5hr suggests other causes, including cholecystitis, cholangitis, or pancreatitis
• Nausea and vomiting

Physical Exam

• Often benign; as compared to cholecystitis, usually negative Murphy's Sign
• May have mild RUQ or epigastric tenderness, or voluntary guarding due to anticipated tenderness
• Usually afebrile with normal vital signs, except for possibly tachycardia due to pain or dehydration

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

Evaluation

Biliary sludge and gallstones. There is borderline thickening of the gallbladder wall.

Gallstones found incidentally on KUB (xrays are not sensitive).

Large gallstone as seen on CT.

• Labs
  • CBC expected to be normal
  • LFTs
  • Consider bilirubin, alkaline phosphatase, and GGT if common bile duct pathology is suspected
• RUQ Ultrasound is the first-line study
  • Will show echogenic stones with posterior acoustic shadowing, dependent on positioning
  • No pericholecystic fluid, thickened gallbladder wall, or distended gallbladder to suggest cholecystitis
  • Sensitivity 84%, Specificity 99%
• CT abdomen/pelvis can be considered if suspecting pathology in the biliary tree and distal CBD, or if other intra-abdominal pathology is suspected

Management

• IV/IM ketorolac
• morphine or hydromorphone
  • Despite the theoretical increase in sphincter of Oddi pressure, opioids are still indicated if pain is refractory to NSAIDs

Disposition

• Discharge
  • Provide early follow-up with a general surgeon for elective cholecystectomy
  • Counsel for low-fat diet and provide prescription for analgesics
• Consider admission for cholecystectomy if intractable abdominal pain or vomiting, large gallstones, porcelain gallbladder, or signs of peritonitis

See Also

• Gallbladder Disease (Main)
• Biliary ultrasound