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

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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.

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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

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

• 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