Symptomatic cholelithiasis

Background

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 that is constant, lasts 1-5hr, and then remits
  • Pain >5hr suggests cholecystitis, cholangitis, or pancreatitis
• Usually does not occur during fasting
• Radiation to the right shoulder increases likelihood, but is not sensitive

Physical Exam

• Often benign; as compared to cholecystitis, usually negative Murphy's Sign

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

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

• Labs
  • LFTs, CBC normal
• RUQ Ultrasound
  • Sensitivity 84%, Specificity 99%

Management

• IV/IM ketorolac vs. morphine
  • Prescription for ibuprofen or opioid

Disposition

• Discharge

See Also

• Gallbladder Disease (Main)
• Biliary ultrasound