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.

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

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
  • LFT, CBC normal
• RUQ Ultrasound
  • Sensitivity 84%, Specificity 99%

Management

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

Disposition

• Outpatient management

See Also

• Gallbladder Disease (Main)

See Also

• Gallbladder Disease (Main)
• Biliary ultrasound