Gallstone Diseases
Biliary colic: dull RUQ/epigastric ...
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Description

Gallstone Diseases

Biliary colic: dull RUQ/epigastric pain, 30 min-6 hrs, caused by GB contracting around sludge/stone often postprandial

Cholelithiasis: Presence of stones in the gallbladder (6% of men, 9% of women); labs typically normal

 • Stone Types: Cholesterol (most common) -> 5 Fs: fat, female, forty, fertile (multiparous), fair (Caucasian); Pigment: Crohn’s/ileal disease, extravascular hemolysis, TPN

 • Imaging: best test is RUQUS (sens 84%, spec 99%) showing stones in GB; CT has poor sensitivity (55-80%)

 • Treatment: Asymptomatic: observe; CCY only if at increased risk for gallbladder carcinoma (stone >3cm, porcelain gallbladder, gallbladder adenoma); Symptomatic (“biliary colic”): elective CCY (67% recurrence rate if no CCY)

Choledocholithiasis: gallstone in CBD; complications: acute pancreatitis, acute cholangitis; WBC - ; AST/ALT- / ↑; AlkP↑↑; Bilis ↑↑

 • Clinical Manifestations: RUQ pain, n/v, jaundice; sx may be intermittent if “ball-valve” effect

 • Imaging: RUQUS to look for CBD dilation >6mm (poor sensitivity for visualizing stones themselves), MRCP if equivocal.

 • Treatment: Endoscopic or surgical stone removal (ERCP ± CCY)

Cholecystitis: Calculous (gallstone in cystic duct) or acalculous (10% of cases, usually critically ill pts, starts as bile stasis “sludge” or gallbladder ischemia); often caused by sterile inflammation of gallbladder ± secondary infection. WBC↑↑, other labs WNL

 • Clinical Manifestations: RUQ pain, fever, Murphy’s sign; jaundice uncommon

     o Acalculous cholecystitis: Unexplained fever, leukocytosis, vague abd pain ± jaundice ± RUQ mass in ICU pt or jaundice in pt post-CCY. Risk factors: trauma, burns, TPN, critical illness, fasting, sepsis 

 • Imaging: RUQUS (GB wall thickening, pericholecystic fluid, sonographic Murphy’s sign), HIDA scan if RUQUS negative

 • Treatment: antibiotics—may not ↓mortality but often given empirically (Zosyn OR [ciprofloxacin/CTX AND metronidazole]), consider stopping abx 1d after definitive intervention. Early (<7d) CCY during hospitalization ↓ morbidity if ↓ surgical risk; GB drainage (i.e. perc chole) if ↑risk and unimproved w/ abx+bowel rest

Cholangitis: asc biliary infx 2/2 obstruction (stone/stent/malignancy/post-ERCP/PSC) WBC ↑↑;AST/ALT - / ↑; AlkP ↑↑; Bilis ↑↑

 • Clinical Manifestations: Charcot’s triad (RUQ pain, fever, jaundice), Reynolds’ pentad (Charcot’s triad + AMS, shock)

 • Imaging: RUQUS (CBD >6mm); may proceed directly to ERCP (i.e., no US) if pt has Charcot’s triad + cholestasis

 • Treatment: antibiotics (Zosyn OR [ciprofloxacin/ceftriaxone AND metronidazole] x7-10d); CBD drainage (ERCP or PCT if ERCP not feasible); CCY during hospitalization



#Gallstone #Diseases #Diagnosis #Management #Summary #Differential
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