1. Gallstones Disease Gallstone Disease Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222

2. Gallstones Disease Overview Gallstone pathogenesis Definitions Differential Diagnosis of RUQ pain 7 Cases

3. Gallstones Disease Gallstone Pathogenesis Bile = bile salts, phospholipids, cholesterol –Also bilirubin which is conjugated b4 excretion Gallstones due to imbalance rendering cholesterol & calcium salts insoluble Pathogenesis involves 3 stages: –1. cholesterol supersaturation in bile –2. crystal nucleation –3. stone growth

4. Gallstones Disease Definitions Symptomatic cholelithiasis Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT Acute cholecystitis Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrest Chronic cholecystitis Recurrent bouts of colic/acute chol’y leading to chronic GB wall inflamm/fibrosis. No fever/WBC. Acalculous cholecystitis GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts Choledocho- lithiasis Gallstone in the common bile duct (primary means originated there, secondary = from GB) CholangitisInfection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic shock

5. Gallstones Disease Differential Diagnosis of RUQ pain Biliary disease –Acute chol’y, chronic chol’y, CBD stone, cholangitis Inflamed or perforated duodenal ulcer Hepatitis Also need to rule out: –Appendicitis, renal colic, pneumonia or pleurisy, pancreatitis

6. Gallstones Disease Case 1 46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now. No prior episodes Minimal RUQ tenderness, no Murphy’s WBC 8, LFT normal RUQ U/S reveals cholelithiasis without GB wall thickening or pericholecystic fluid Diagnosis: ?

7. Gallstones Disease Case 1 → denotes gallstones ► denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone → → ►

8. Gallstones Disease Symptomatic cholelithiasis aka “biliary colic” The pain occurs due to a stone obstructing the cystic duct, causing wall tension; pain resolves when stone passes Pain usually lasts 1-5 hrs, rarely > 24hrs Ultrasound reveals evidence at the crime scene of the likely etiology: gallstones Exam, WBC, and LFT normal in this case Treatment: Laparoscopic cholecystectomy

9. Gallstones Disease Spectrum of Gallstone Disease Cholelithiasis Asymptomatic cholelithiasis Symptomatic cholelithiasis Chronic calculous cholecystitis Acute calculous cholecystitis Symptomatic cholelithiasis can be a herald to: –an attack of acute cholecystitis –or ongoing chronic cholecystitis May also resolve

10. Gallstones Disease Case 2 Same case, except pt has had multiple prior attacks of similar RUQ pain No fever or WBC Ultrasound reveals gallstones, thickened GB wall, no pericholecystic fluid Diagnosis: ?

11. Gallstones Disease Chronic calculous cholecystitis Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones Overtime, leads to scarring/wall thickening Treatment: laparoscopic cholecystectomy

12. Gallstones Disease Case 3 Same pt, now > 24hrs of RUQ pain radiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever Exam: Palpable, tender gallbladder, guarding, +Murphy’s = inspiratory arrest WBC 13, Mild ↑LFT U/S: gallstones, wall thickening (>4mm), GB distension, pericholecystic fluid, sonographic Murphy’s sign (very specific) Diagnosis: ?

13. Gallstones Disease Case 3 Curved arrow –Two small stones at GB neck Straight arrow –Thickened GB wall ◄ –pericholecystic fluid = dark lining outside the wall ◄

14. Gallstones Disease Case 3 → denotes the GB wall thickening ► denotes the fluid around the GB GB also appears distended → ►

15. Gallstones Disease Acute calculous cholecystitis Persistent cystic duct obstruction leads to GB distension, wall inflammation & edema Can lead to: empyema, gangrene, rupture Pain usu. persists >24hrs & a/w N/V/Fever Palpable/tender or even visible RUQ mass Nuclear HIDA scan shows nonfilling of GB –If U/S non-diagnostic, obtain HIDA Tx: NPO, IVF, Abx (GNR & enterococcus) Sg: Cholecystectomy usu within 48hrs

16. Gallstones Disease Case 4 87yo M critically ill, on long-term TPN w RUQ pain, fever, ↑WBC Ultrasound: GB wall thickening, pericholecystic fluid, no gallstones Diagnosis: ?

17. Gallstones Disease Acute acalculous cholecystitis In 5-10% of cases of acute cholecystitis Seen in critically ill pts or prolonged TPN More likely to progress to gangrene, empyema, perforation due to ischemia Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin Tx: Emergent cholecystectomy usu open If pt is too sick, perc cholecystostomy tube and interval cholecystectomy later on

18. Gallstones Disease Complications of acute cholecystitis Empyema of gallbladder Pus-filled GB due to bacterial proliferation in obstructed GB. Usu. more toxic, high fever Emphysematous cholecystitis More commonly in men and diabetics. Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumen Perforated gallbladder Occurs in 10% of acute chol’y, usually becomes a contained abscess in RUQ Less commonly, perforates into adjacent viscus = cholecystoenteric fistula & the stone can cause SBO (gallstone ileus)

19. Gallstones Disease Case 5 46yo F p/w RUQ pain, jaundice, acholic stools, dark tea-colored urine, no fevers Known history of cholelithiasis Exam: unremarkable WBC 8, T.Bili 8, AST/ALT NL, HepB/C neg Ultrasound: Gallstones, CBD stone, dilated CBD > 1cm Diagnosis: ?

20. Gallstones Disease Choledocholithiasis Can present similarly to cholelithiasis, except with the addition of jaundice DDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with pain Tx: Endoscopic retrograde cholangiopancreatography (ERCP) –Stone extraction and sphincterotomy Interval cholecystectomy after recovery from ERCP

21. Gallstones Disease Case 6 46yo F p/w fever, RUQ pain, jaundice (Charcot’s triad) If also altered mental status and signs of shock = Raynaud’s pentad VS tachycardic, hypotensive ABC’s, Resuscitate –2 large bore IV, Foley, Continuous monitor –1-2L fluid bolus, repeat until resuscitated Diagnosis: ?

22. Gallstones Disease Cholangitis Infection of the bile ducts due to CBD obstruction 2ndary to stones, strictures Charcot’s triad seen in 70% of pts May lead to life-threatening sepsis and septic shock (Raynaud’s pentad) Tx: NPO, IVF, IV Abx Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC) Used to require emergency laparotomy

23. Gallstones Disease Case 7 46yo F p/w persistent epigastric & back pain Known history of symptomatic gallstones No EtOH abuse Exam: Tender epigastrum Amylase 2000, ALT 150 Ultrasound: Gallstones Diagnosis: ?

24. Gallstones Disease Gallstone pancreatitis 35% of acute pancreatitis 2ndary 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 Tx: ABC, resuscitate, NPO/IVF, pain meds Once pancreatitis resolving, ERCP w stone extraction/sphincterotomy Cholecystectomy before hospital discharge

25. Gallstones Disease Take Home Points As always, ABC & Resuscitate before Dx Understanding the definitions is key Is this acute cholecystitis? (fever, WBC, tender on exam with positive Murphy’s) Or simply cholelithiasis vs ongoing chronic cholecystitis? (no fever/WBC) Is patient sick or toxic-appearing, to suspect empyema, gangrene or even perforation? Elicit h/o jaundice, acholic stools, tea-colored urine Rule out cholangitis, because this will kill the patient unless dx & tx early