Symptomatic cholelithiasis
(Redirected from 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
- 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
- Pancreatitis
- Acute hepatitis
- Pancreatitis
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Bowel obstruction
- Cirrhosis
- Budd-Chiari syndrome
- GU
- Other
- Hepatomegaly due to CHF
- Peptic ulcer disease with or without perforation
- Pneumonia
- Herpes zoster
- Myocardial ischemia
- Pulmonary embolism
- Abdominal aortic aneurysm
Evaluation
- 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