Cholelithiasis

Snapshot

A 50-year-old woman presents to her family medicine physician’s office due to recurrent abdominal pain. She reports that this often occurs after a meal out, or when she takes her children to get burgers at a fast food chain. She reports that it is primarily in her right upper quadrant, and the pain episodes resolve after an hour. She has a history of hypertension but is otherwise healthy. On physical exam, there are no remarkable findings. She is sent for an ultrasound to evaluate for gallstones.

Introduction

Clinical definition
- cholelithiasis
  - stones in gallbladder are cholesterol or pigment stones
Epidemiology
- demographics
  - female > male
  - adults
- risk factors
  - cholesterol stones (most common)
    - F’s
      - Fat
      - Female
      - Forty
      - Fertile
    - impaired gallbladder emptying
      - total parenteral nutrition
      - starvation
      - diabetes
    - biliary stasis
      - rapid weight loss
    - Native American heritage
  - pigment stones
    - brown
      - result of common bile duct infection
      - result of bacterial-mediated release of beta-glucuronidase leading to formation of unconjugated bilirubin and glucoronic acid
      - unconjugated bilirubin levels rise and result in brown pigmented stones
    - black
      - composed of calcium bilirubinate
      - result of ↑ liver excretion of bilirubin secondary to chronic RBC degradation
Pathogenesis
- cholesterol saturation can cause impaired gallbladder motility
- gallstones can lead to mechanical obstruction of biliary tract and cause bacterial overgrowth
Associated conditions
- acute cholecystitis
- ascending cholangitis
- acute pancreatitis
gallstone ileus

Presentation

Imaging

Right upper quadrant ultrasound
- findings
  - gallstones
Magnetic resonance cholangiopancreatography (MRCP)
- indication
  - ultrasound results are equivocal
Endoscopic retrograde cholangiopancreatography (ERCP)
- indication
  - both diagnostic and therapeutic
if intervention is indicated

Studies

Serum labs
- alkaline phosphatase and bilirubin may be elevated but only mildly
- amylase
to assess for gallstone pancreatitis

Differential

Peptic ulcer disease
- distinguishing factors
  - epigastric gnawing pain that may improve with meals
  - ultrasound will show no signs of biliary disease
Sphincter of Oddi dysfunction
- distinguishing factors
  - presents similarly to biliary colic
  - diagnosed with manometry
treated with sphincterotomy via ERCP

Treatment

Complications