Gallstone Disease
GENERAL PRINCIPLES
Asymptomatic gallstones (cholelithiasis) are a common incidental finding for which no specific therapy is generally necessary. Cholesterol stones are the most common type, but pigmented stones can be seen with hemolysis or infection.
Risk factors include obesity, female gender, parity, rapid weight loss, ileal disease, and maternal family history. Symptomatic cholelithiasis, when upper abdominal symptoms are linked to gallstones, is typically treated surgically with cholecystectomy.
Acute cholecystitis is caused most often by a gallstone obstructing the cystic duct, but acalculous cholecystitis can occur in critically ill patients.
Choledocholithiasis refers to stones within the bile ducts.
Cholangitis is infection of the bile ducts, usually caused by an impacted gallstone in the distal bile duct.
DIAGNOSIS
Clinical Presentation
Cholelithiasis may present as biliary colic, a constant pain lasting for several hours, located in the right upper quadrant, radiating to the back or right shoulder, and sometimes associated with nausea or vomiting. Pain that lasts longer than several hours may suggest complications including choledocholithiasis or cholecystitis.
Other presentations of gallstone disease include acute cholecystitis, acute pancreatitis, and cholangitis. Gallstone disease may rarely be associated with gallbladder cancer.
Two-thirds of patients with acute ascending cholangitis present with right upper quadrant pain, fever with chills and/or rigors, and jaundice (Charcot triad), in the setting of biliary obstruction (choledocholithiasis, neoplasia, sclerosing cholangitis, biliary stent occlusion). The additional presence of hypotension and altered mentation defines the Reynolds pentad.
Diagnostic Testing
Ultrasound scans have a high degree of accuracy in diagnosis (sensitivity and specificity gt;95%) and are the preferred initial test.
Hydroxy iminodiacetic acid (HIDA) scan can demonstrate nonfilling of the gallbladder in patients with acute cholecystitis, although false-negative results may be seen in acalculous cholecystitis.
MRCP is better than CT at visualizing the biliary tree. It can identify biliary ductal dilation and often the level of obstruction from a gallstone or mass. A pancreas protocol CT can be useful if a pancreatic mass is suspected as the cause of biliary obstruction.
EUS is sensitive for detecting obstructing gallstones and allows for therapeutic ERCP to be done in the same setting.
TREATMENT
Medications
Supportive measures include IV fluid resuscitation and broad-spectrum antimicrobial agents, especially in the event of complications such as acute cholecystitis with sepsis, perforation, peritonitis, abscess, or empyema formation.
Ursodeoxycholic acid (8-10 mg/kg/d PO in two to three divided doses for prolonged periods) might be prudent in a select group of patients with small cholesterol stones in normally functioning gallbladders who are at high risk for complications from surgical therapy. Side effects include diarrhea and reversible elevation in serum transaminases.
Nonpharmacologic Therapies
Percutaneous cholecystostomy can be performed under fluoroscopy in severely ill patients with acute cholecystitis who are not surgical candidates, especially for acalculous cholecystitis.
Surgical Management
Cholecystectomy is the therapy of choice for symptomatic gallstone disease and acute cholecystitis. Laparoscopic cholecystectomy is now standard of care. Open cholecystectomy is rarely performed.
ERCP is now used primarily for therapeutic intervention, since MRCP and/or EUS are less invasive and provide enhanced diagnostic potential. Patients presenting with symptomatic cholelithiasis should be assessed as low or high risk of having choledocholithiasis based on laboratory evidence of biliary obstruction and biliary dilation on imaging.
Patients at high risk for choledocholithiasis should undergo ERCP for stone removal prior to cholecystectomy. Patients at intermediate risk should either undergo further testing with EUS or MRCP, followed by ERCP if positive, or have an intraoperative cholangiogram during cholecystectomy.96 An ERCP can be performed subsequently if choledocholithiasis is found.Complications
Acute pancreatitis: See Acute Pancreatitis section.
Choledocholithiasis: Common bile duct obstruction, jaundice, biliary colic, cholangitis, or pancreatitis can result from stones retained in the common bile duct. The diagnosis can be made on ultrasonography, CT, or MRCP. ERCP with sphincterotomy and stone extraction is curative. The patient should be referred for cholecystectomy.
Acute ascending cholangitis represents a medical emergency with high morbidity and mortality if biliary decompression is not performed urgently. The condition should be stabilized with IV fluids and broad-spectrum antibiotics. Drainage of the biliary tree can be performed through endoscopic (ERCP with sphincterotomy) or percutaneous approaches under fluoroscopic guidance.