Gallstone Diseas Egolf_2

8/6/2019 Gallstone Diseas Egolf_2

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Gallstone Disease

Gallstone Disease

Nachapan Pengrung , M.D


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Gallstone Disease

Definitions

Cholelithiasis = gallstones Acute calculous cholecystitis = 2/2 occlusion of the cystic duct

by gallstone leading to gallbladder inflammation

Chronic calculous cholecystitis = recurrent episodes of cystic

duct obstruction leading to scarring and a nonfunctional

gallbladder Chronic acalculous cholecystitis = symptoms of biliary colic, no

gallstones, and an abnormal gallbladder ejection fraction

Acute cholangitis = bacterial infection of the biliary ducts

Choledocholithiasis = CBD stones

Mirizzi syndrome = when gallstones lodged in either the cysticduct or the Hartmann pouch of the gallbladder, externally

compressed the common hepatic duct (CHD), causing

symptoms of obstructive jaundice


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Gallstone Disease

Bile

Bile

Bile salts (primary: cholic, chenodeoxycholic acids;

secondary: deoxycholic, lithocholic acids)

Phospholipids (90% lecithin) Cholesterol

Cholesterol solubility depends on the relative

concentration of cholesterol, bile salts, and

phospholipid


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Gallstone Disease

Types of Gallstones Mixed (80%)

Pure cholesterol (10%)

Pigmented (10%)

Black stones (contain Ca bilirubinate, a/w

cirrhosis and hemolysis)

Brown stones (a/w biliary tract infection)


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Gallstone Disease

Gallstone Pathogenesis Pathogenesis of cholesterol gallstones involves: (1)

cholesterol supersaturation in bile, (2) crystal

nucleation, (3) gallbladder dysmotility, (4) gallbladderabsorption

Black pigment stones: contain Ca++ salts, a/w

hemolytic conditions or cirrhosis, found in the

gallbladder

Brown pigment stones: Asians, contain Ca++

palmitate, found in bile ducts, a/w biliary dysmotility

and bacterial infection


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Gallstone Disease

Gallstone Risk Factors

Female, Fat, Forty, Fertile Oral contraceptives

Obesity

Rapid weight loss (gastric bypass pts)

Fatty diet

DM

Prolonged fasting TPN

Ileal resection

Hemolytic states

Cirrhosis

Bile duct stasis (biliary stricture, congenital cysts, pancreatitis,sclerosing cholangitis)

IBD

Vagotomy

Hyperlipidemia


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Gallstone Disease

Gallstone Complications

Gallstone ileus, gallstone pancreatitis

Acute cholecystitis: 10-20% of pts w/ symptomatic gallstones

GB gangrene

GB perforation

GB empyema (pus in the GB) Emphysematous cholecystitis (a/w GB vascular

compromise, stones, impaired immune system, infection

w/gas-forming organisms - clostridium, E. coli, Klebsiella)

Cholecystoenteric fistula

Choledochohlithiasis: 8-15% of pts w/ symptomatic gallstones Cirrhosis

Cholangitis

Pancreatitis


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Gallstone Disease

Symptomatic Gallstones

Provocation/Timing: meals (50%), nighttime

Quality: constant

Radiation: RUQ to the R scapula (Boas sign)

Severity: severe

PE: (+)Murphys sign


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Gallstone Disease

RUQ DDx

Gallbladder: cholecystitis, choledocholithiasis,

cholangitis

Duodenal ulcer

Hepatitis

Appendicitis (atypical presentation)

PNA

Pancreatitis


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Gallstone Disease

Labs

Order: BMP, amylase/lipase, LFTs, CBC,

coags

Acute cholecystitis: increased WBC,

increased alk phos, slight increase in

amylase and T bili


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Gallstone Disease

Imaging

KUB - only 15% of gallstones are radiopaque U/S - gallstone identification false(-) rate is 5-15%. It identifies

bile duct dilatation w/ 80% accuracy.

Look for: thickened GB wall (>3mm), pericholecystic fluid,distended GB, Murphys sign

HIDA scan - radionuclide IV, extracted from blood, excreted into

bile Uptake by liver, GB, CBD, duodenum w/in 1hr = normal

Slow uptake = hepatic parenchymal disease

Filling of GB/CBD w/delayed or absent filling of intestine =obstruction of ampulla

Non-visualization of GB w/ filling of the CBD and duodenum= cystic duct obstruction and acute cholecystitis (95%sensitivity & specificity)

CT scan - used to diagnose complications

MRI - can detect gallstones and common duct stones

ERCP - to look for CBD stones


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Gallstone Disease

Strasberg S. N Engl J Med 2008;358:2804-2811

Ultrasonographic Images of Three Gallbladders


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Gallstone Disease


Hepatobiliary Scintigraphy


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Gallstone Disease

Thomas L et al. N Engl J Med 1999;341:1134-1138

CT Scan of the Abdomen


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Gallstone Disease


Diagnostic Criteria for Acute Cholecystitis, According to Tokyo Guidelines


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Gallstone Disease

Cholecystitis: Management

NPO, IVF, IV antibiotics

Non-operative: dissolution therapy ursodeoxycholic

acid, chenodeoxycholic acid

Operative: cholecystectomy

For unstable pts: percutaneous transhepatic

cholecystostomy (CT or U/S guided)


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Gallstone Disease

Indications for Prophylactic Cholecystectomy

Pediatric gallstones

Congenital hemolytic anemia

Gallstones >2.5cm

Porcelain gallbladder

Bariatric surgery

Incidental gallstones found during intraabdominal

surgery Recommended prior to transplantation


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Gallstone Disease

Case 1

HPI: 46y F p/w 4hr h/o nausea and RUQ pain radiating

to the R scapula. Symptoms began 1 hr after a fatty

meal. Pt currently has no pain. No prior episodes.

PMHx/PSHx None PE: RUQ minimally TTP, (-)Murphys

Labs: WBC 8, LFT normal

Studies: RUQ U/S w/cholelithiasis without GB wall

thickening or pericholecystic fluid

What is the diagnosis?


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Gallstone Disease

Case 1

denotes

gallstones

denotes the

acoustic shadow

due to absence of

reflected sound

waves behind the

gallstone


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Gallstone Disease

Case 1: Continued

Dx: symptomatic cholethiasis

Plan: NPO, IVF, cholecystectomy


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Gallstone Disease

Case 2

46y F p/w 4hr h/o nausea and RUQ pain radiating to theR scapula. Symptoms began 1 hr after a fatty meal. Ptcurrently has no pain. Has had multiple similarepisodes.

PMHx/PSHx None PE: RUQ minimally TTP, (-)Murphys

Labs: WBC 6, LFT normal

Studies: RUQ U/S w/cholelithiasis without GB wallthickening or pericholecystic fluid

Diagnosis: ?


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Gallstone Disease

Case 2: Continued Dx: chronic calculous cholecystitis

Recurrent inflammatory process due to

recurrent cystic duct obstruction leading to

scarring/wall thickening

Treatment: cholecystectomy


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Gallstone Disease

Case 3

46yF p/w h/o >24hr of RUQ pain radiating to the R

scapula, started after fatty meal, a/w nausea, vomiting,

fever

Exam: Febrile, RUQ TTP, (+)Murphys sign Labs: WBC 13, Mild LFT

U/S: gallstones, wall thickening, GB distension,

pericholecystic fluid, sonographic Murphys sign



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Gallstone Disease

Case 3: Continued Curved arrow

Two small stones

at GB neck

Straight arrow

Thickened GB wall

pericholecystic

fluid = dark lining

outside the wall


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Gallstone Disease

Case 3: Continued

denotes the GB

wall thickening

denotes the fluid

around the GB

GB also appearsdistended


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Gallstone Disease

Case 3: Continued

Dx: acute calculous cholecystitis

Persistent cystic duct obstruction leads to GB distension, wallinflammation & edema

Risk of: empyema, gangrene, rupture

Treatment: NPO

IVF

ABX:

Common organisms: E coli, Bacteroides fragilis,

Klebsiella, Enterococcus, and Pseudomonas Piperacillin/tazobactam (Zosyn), ampicillin/sulbactam

(Unasyn), or meropenem

Cholecystectomy


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Gallstone Disease

Case 4

87y M critically ill, on long-term TPN c/o

RUQ pain

PE: febrile, RUQ TTP

U/S: GB wall thickening, pericholecystic

fluid, no gallstones



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Gallstone Disease

Case 4: Continued

Dx: acute acalculous cholecystitis

Caused by gallbladder stasis from lack of enteral

stimulation by cholecystokinin

Risk of: gangrene, empyema, perforation due to

ischemia

TX: cholecystectomy

If pt is too sick, percutaneous cholecystostomytube followed by cholecystectomy


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Gallstone Disease

Case 5

46y F p/w RUQ pain, jaundice, acholic stools,

dark tea-colored urine, w/o fever

PMHx: cholelithiasis

Exam: unremarkable WBC 8, T.Bili 8, AST/ALT NL, Hep B/C neg

U/S: gallstones, CBD stone, dilated CBD >

1cm



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Gallstone Disease

Case 5: Continued

DX: choledocholithiasis

Similar presentation as cholelithiasis, except with the

addition of jaundice

DDx: cholelithiasis, hepatitis, cholangitis, CA,choledochal cyst, bile duct stricture, UC, pancreatitis

Plan:

Endoscopic retrograde cholangiopancreatography

(ERCP) w/ stone extraction and sphincterotomy

Interval cholecystectomy after recovery from

ERCP


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Gallstone Disease

Case 6: Continued

Dx: cholangitis

Infection of the bile ducts due to CBD obstruction secondary tostones/strictures

Common organisms: E. coli, Klebsiella, Pseudomonas,Enterobacter, Proteus, Serratia

70% p/w Charcots

May lead to life-threatening sepsis and septic shock (Raynaudspentad)

Common lab findings: leukocytosis, hyperbili, elevated alk phos

Treatment:

NPO, IVF, IV ABX

Emergent decompression via ERCP or perc transhepaticcholangiogram (PTC)


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Gallstone Disease

Case 7

46y F p/w persistent epigastric & back pain

PMHx: symptomatic gallstones

SHx: no ETOH

PE: Tender epigastrum Labs: Amylase 2000, ALT 150

U/S: gallstones


What is the plan?


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Gallstone Disease

Case 7: Continued

Dx: gallstone pancreatitis

35% of acute pancreatitis secondary to stones

Pathophysiology: reflux of bile into pancreatic duct

and/or obstruction of ampulla by stone

ALT >150 (3-fold elevation) has 95% PPV for diagnosing

gallstone pancreatitis

Treatment:

ABC, resuscitate, NPO/IVF, pain medication

ERCP once pancreatitis resolves

Cholecystectomy before d/c


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Gallstone Diseas Egolf_2

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