Cholelithiasis (Gallstones)
Discuss cholelithiasis?
Gallstones are fairly common (20% of women and 8% of men), however less than 50% of those with gallstones actually have symptoms, and fewer than 10% develop potentially life-threatening complications.
Discuss the clinical presentations of cholelithiasis?
Biliary colic typically described as postprandial epigastric or RUQ pain (steady, non paroxysmal pain, rapidly increases in intensity then plateaus), sometimes radiating to the interscapular region or up to the right shoulder. The pain may last from several minutes to several hours (usually less than 4 hours). Intense pain is often accompanied by nausea and vomiting. Occasionally, the pain may be in the left upper quadrant.
Biliary colic is usually caused by the gallbladder contracting due to a fatty meal, forcing a stone against the gallbladder outlet or cystic duct opening, and leading to increased intra gallbladder pressure and pain. The stones often fall back from the cystic duct as the gallbladder relaxes. In most patients the pain is not very severe. There is not much to find on physical examination.
Acute cholecystitis-patients with acute cholecystitis experience severe pain that persists for several hours (6hrs or more), until they finally seek help at a local emergency department. Whereas in biliary colic the cystic duct obstruction is transient, in acute cholecystitis it is persistent. Persistent cystic duct obstruction, in combination with chemical irritants in the bile, results in inflammation and edema of the gallbladder wall. Nausea and vomiting are common. Physical examination usually reveals marked tenderness in the right upper quadrant, often associated with a definite mass or fullness. Murphy’s sign is positive. Fever and local peritoneal signs are common.
Gallstone pancreatitis (see acute pancreatitis)
Choledocholithiasis and cholangitis- presents with fever, jaundice and pain.
Gallstone ileus- is caused by impaction of a gallstone in the ileum after being passed through a biliary-enteric fistula. It presents with episodic sub acute obstruction in an elderly female. The mainstay of treatment is removal of the obstructing stone after resuscitating the patient.
Discuss the investigations for cholelithiasis?
USS- is the investigation of choice for suspected gall stones. Positive findings include stones, thickening of the gallbladder wall, pericholecystic fluid, and a positive Murphy sign on contact with the ultrasonographic probe. These findings are particularly indicative of acute cholecystitis.
Computed tomography is not as accurate as USS in detecting gallstones since most stones are isodense with bile and thus not visible on CT scanning. CT can be useful in patients in whom medical therapy is being considered since the presence of calcifications within gallstones (readily apparent on CT) makes it unlikely that such therapy will be successful.
MRCP – when stones in CBD are suspected.
CT cholangiography- is indicated in patients with suspected choledocholithiasis when MRI is contraindicated. The technique involves an injection of contrast that is excreted in bile as the patient is imaged in the CT scanner. The test relies upon the excretion of contrast in bile. Obstructive jaundice is a relative contraindication. In general, it is not possible to obtain good images of the biliary tree if the bilirubin is twice the upper limit of the normal range. This technique can give excellent pictures of the biliary tree but will not show the gallbladder at all unless the cystic duct is patent – and hence is less useful in cases of biliary colic or cholecystitis.
Discuss the management of cholelithiasis?
Asymptomatic gallstones do not need any treatment.
Laparoscopic cholecystectomy is now the gold standard in the treatment of symptomatic gallbladder disease. It is effective and safe, with low rates of complications and mortality (<0.1%).
Discuss cholecystectomy in cirrhotic patients?
Patients with symptomatic gallstones and compensated cirrhosis (i.e., Child’s class A or B) should be considered for a cholecystectomy. In a meta-analysis of six studies comparing outcomes after cholecystectomy in patients with and without cirrhosis, patients with cirrhosis had no significant difference in mortality rate. However, overall complications such as liver bleeding and new onset ascites were higher in patients with cirrhosis compared with those without cirrhosis (21 versus 8 percent, respectively). Although the studies on cholecystectomy in patients with Child class C cirrhosis are not large enough to yield significant results, unacceptably high mortality rates have been reported. Therefore, it is generally agreed that a more conservative approach is warranted in patients with Child class C cirrhosis and symptomatic gallstone disease, directing treatment toward improving their liver function before cholecystectomy.
Discuss the nonsurgical treatment of gallstone disease?
Oral dissolution therapy using 10 mg per kg per day of ursodeoxycholic acid (UDCA) can be used in patients unfit or unwilling to undergo surgery. This treatment is suitable for small cholesterol rich stones without any calcification and good gallbladder function. Treatment may be required for up to 2 years depending on the size of the stone. Gallstone recurrence is a disadvantage of this treatment; approximately 25 percent of patients develop recurrent gallstones within five years.
Extracorporeal shockwave lithotripsy (ESWL) may be used with UDCA in patients with stones too large for dissolution therapy.
Ref
Discuss cholelithiasis?
Gallstones are fairly common (20% of women and 8% of men), however less than 50% of those with gallstones actually have symptoms, and fewer than 10% develop potentially life-threatening complications.
Discuss the clinical presentations of cholelithiasis?
Biliary colic typically described as postprandial epigastric or RUQ pain (steady, non paroxysmal pain, rapidly increases in intensity then plateaus), sometimes radiating to the interscapular region or up to the right shoulder. The pain may last from several minutes to several hours (usually less than 4 hours). Intense pain is often accompanied by nausea and vomiting. Occasionally, the pain may be in the left upper quadrant.
Biliary colic is usually caused by the gallbladder contracting due to a fatty meal, forcing a stone against the gallbladder outlet or cystic duct opening, and leading to increased intra gallbladder pressure and pain. The stones often fall back from the cystic duct as the gallbladder relaxes. In most patients the pain is not very severe. There is not much to find on physical examination.
Acute cholecystitis-patients with acute cholecystitis experience severe pain that persists for several hours (6hrs or more), until they finally seek help at a local emergency department. Whereas in biliary colic the cystic duct obstruction is transient, in acute cholecystitis it is persistent. Persistent cystic duct obstruction, in combination with chemical irritants in the bile, results in inflammation and edema of the gallbladder wall. Nausea and vomiting are common. Physical examination usually reveals marked tenderness in the right upper quadrant, often associated with a definite mass or fullness. Murphy’s sign is positive. Fever and local peritoneal signs are common.
Gallstone pancreatitis (see acute pancreatitis)
Choledocholithiasis and cholangitis- presents with fever, jaundice and pain.
Gallstone ileus- is caused by impaction of a gallstone in the ileum after being passed through a biliary-enteric fistula. It presents with episodic sub acute obstruction in an elderly female. The mainstay of treatment is removal of the obstructing stone after resuscitating the patient.
Discuss the investigations for cholelithiasis?
USS- is the investigation of choice for suspected gall stones. Positive findings include stones, thickening of the gallbladder wall, pericholecystic fluid, and a positive Murphy sign on contact with the ultrasonographic probe. These findings are particularly indicative of acute cholecystitis.
Computed tomography is not as accurate as USS in detecting gallstones since most stones are isodense with bile and thus not visible on CT scanning. CT can be useful in patients in whom medical therapy is being considered since the presence of calcifications within gallstones (readily apparent on CT) makes it unlikely that such therapy will be successful.
MRCP – when stones in CBD are suspected.
CT cholangiography- is indicated in patients with suspected choledocholithiasis when MRI is contraindicated. The technique involves an injection of contrast that is excreted in bile as the patient is imaged in the CT scanner. The test relies upon the excretion of contrast in bile. Obstructive jaundice is a relative contraindication. In general, it is not possible to obtain good images of the biliary tree if the bilirubin is twice the upper limit of the normal range. This technique can give excellent pictures of the biliary tree but will not show the gallbladder at all unless the cystic duct is patent – and hence is less useful in cases of biliary colic or cholecystitis.
Discuss the management of cholelithiasis?
Asymptomatic gallstones do not need any treatment.
Laparoscopic cholecystectomy is now the gold standard in the treatment of symptomatic gallbladder disease. It is effective and safe, with low rates of complications and mortality (<0.1%).
Discuss cholecystectomy in cirrhotic patients?
Patients with symptomatic gallstones and compensated cirrhosis (i.e., Child’s class A or B) should be considered for a cholecystectomy. In a meta-analysis of six studies comparing outcomes after cholecystectomy in patients with and without cirrhosis, patients with cirrhosis had no significant difference in mortality rate. However, overall complications such as liver bleeding and new onset ascites were higher in patients with cirrhosis compared with those without cirrhosis (21 versus 8 percent, respectively). Although the studies on cholecystectomy in patients with Child class C cirrhosis are not large enough to yield significant results, unacceptably high mortality rates have been reported. Therefore, it is generally agreed that a more conservative approach is warranted in patients with Child class C cirrhosis and symptomatic gallstone disease, directing treatment toward improving their liver function before cholecystectomy.
Discuss the nonsurgical treatment of gallstone disease?
Oral dissolution therapy using 10 mg per kg per day of ursodeoxycholic acid (UDCA) can be used in patients unfit or unwilling to undergo surgery. This treatment is suitable for small cholesterol rich stones without any calcification and good gallbladder function. Treatment may be required for up to 2 years depending on the size of the stone. Gallstone recurrence is a disadvantage of this treatment; approximately 25 percent of patients develop recurrent gallstones within five years.
Extracorporeal shockwave lithotripsy (ESWL) may be used with UDCA in patients with stones too large for dissolution therapy.
Ref
David P. Vogt. Gallbladder disease: An update on diagnosis and treatment. Cleveland clinic of journal of medicine. Vol 69 No 12
http://www.ccjm.org/content/69/12/977.long
