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10/13/2015

Gallstones(Cholelithiasis)ClinicalPresentation:History,PhysicalExamination

Gallstones(Cholelithiasis)ClinicalPresentation
Author:DouglasMHeuman,MD,FACP,FACG,AGAFChiefEditor:JulianKatz,MDmore...
Updated:Jan20,2015

History
Gallstonediseasemaybethoughtofashavingthefollowing4stages:
1.
2.
3.
4.

Thelithogenicstate,inwhichconditionsfavorgallstoneformation
Asymptomaticgallstones
Symptomaticgallstones,characterizedbyepisodesofbiliarycolic
Complicatedcholelithiasis

Symptomsandcomplicationsofgallstonediseaseresultfromeffectsoccurring
withinthegallbladderorfromstonesthatescapethegallbladdertolodgeinthe
commonbileduct.

Asymptomaticgallstones
Gallstonesmaybepresentinthegallbladderfordecadeswithoutcausingsymptoms
orcomplications.Inpatientswithasymptomaticgallstonesdiscoveredincidentally,
thelikelihoodofdevelopingsymptomsorcomplicationsis12%peryear.Inmost
cases,asymptomaticgallstonesdonotrequireanytreatment.
Becausetheyarecommon,gallstonesoftencoexistwithothergastrointestinal
conditions.Thereislittleevidencetosupportacausalassociationbetween
gallstonesandchronicabdominalpain,heartburn,postprandialdistress,bloating,
flatulence,constipation,ordiarrhea.
Dyspepsiathatoccursreproduciblyfollowingingestionoffattyfoodsisoftenwrongly
attributedtogallstones,whenirritablebowelsyndromeorgastroesophagealrefluxis
thetrueculprit.Gallstonesdiscoveredduringanevaluationfornonspecific
symptomsareusuallyinnocentbystanders,andtreatmentdirectedatthegallstones
isunlikelytorelievethesesymptoms.

Biliarycolic
Paintermedbiliarycolicoccurswhengallstonesorsludgefortuitouslyimpactinthe
cysticductduringagallbladdercontraction,increasinggallbladderwalltension.In
mostcases,thepainresolvesover30to90minutesasthegallbladderrelaxesand
theobstructionisrelieved.
Episodesofbiliarycolicaresporadicandunpredictable.Thepatientlocalizesthe
paintotheepigastriumorrightupperquadrantandmaydescriberadiationtothe
rightscapulartip(Collinssign[8]).Thepainbeginspostprandially(usuallywithinan
hourafterafattymeal),isoftendescribedasintenseanddull,andmaylastfrom1
5hours.Fromonset,thepainincreasessteadilyoverabout10to20minutesand
thengraduallywaneswhenthegallbladderstopscontractingandthestonefalls
backintothegallbladder.Thepainisconstantinnatureandisnotrelievedby
emesis,antacids,defecation,flatus,orpositionalchanges.Itmaybeaccompanied
bydiaphoresis,nausea,andvomiting.
Othersymptoms,oftenassociatedwithcholelithiasis,includeindigestion,
dyspepsia,belching,bloating,andfatintolerance.However,thesearevery
nonspecificandoccurinsimilarfrequenciesinindividualswithandwithout
gallstonescholecystectomyhasnotbeenshowntoimprovethesesymptoms.
Mostpatientsdevelopsymptomspriortocomplications.Oncesymptomsofbiliary
colicoccur,severesymptomsdevelopin39%ofpatients,withcomplicationsin1
3%peryearandacholecystectomyrateof38%peryear.Therefore,inpeoplewith
mildsymptoms,50%havecomplicationsafter20years.
Zollingerperformedstudiesinthe1930sinwhichthegallbladderwallorcommon
bileductwasdistendedwithaballoonpainwaselicitedintheepigastricregion.
Onlyifthedistendedgallbladdertouchedtheperitoneumdidthepatientexperience
rightupperquadrantpain.Associatedsymptomsofnausea,vomiting,orreferred
painwerepresentindistentionofthecommonbileduct(CBD)butnotofthe
gallbladder.

PhysicalExamination
Patientswiththelithogenicstateorasymptomaticgallstoneshavenoabnormal
findingsonphysicalexamination.
Distinguishinguncomplicatedbiliarycolicfromacutecholecystitisorother
complicationsisimportant.Bothoftenpresentwiththesameconstellationof
symptoms,andphysicalexaminationmayhelptodifferentiatethetwo.
Sincethegallbladderisnotinflamedinuncomplicatedbiliarycolic,thepainis
poorlylocalizedandvisceralinoriginthepatienthasanessentiallybenign
abdominalexaminationwithoutreboundorguarding.Feverisabsent.
Inacutecholecystitis,inflammationofthegallbladderwithresultantperitoneal
irritationleadstowelllocalizedpainintherightupperquadrant,usuallywith
reboundandguarding.Althoughnonspecific,apositiveMurphysign(inspiratory
arrestondeeppalpationoftherightupperquadrantduringdeepinspiration)is
highlysuggestiveofcholecystitis.Feverisoftenpresent,butitmaylagbehindother

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Gallstones(Cholelithiasis)ClinicalPresentation:History,PhysicalExamination

signsorsymptoms.
Althoughvoluntaryguardingmaybepresent,noperitonealsignsarepresent.
Tachycardiaanddiaphoresismaybepresentasaconsequenceofpain.These
shouldresolvewithappropriatepainmanagement.
Thepresenceoffever,persistenttachycardia,hypotension,orjaundicenecessitate
asearchforcomplicationsofcholelithiasis,includingcholecystitis,cholangitis,
pancreatitis,orothersystemiccauses.
Inseverecasesofacutecholecystitis,ascendingcholangitis,oracutepancreatitis,
bowelsoundsareoftenabsentorhypoactive.
Choledocholithiasiswithobstructionofthecommonbileductproducescutaneous
andscleralicterusthatevolvesoverhourstodaysasbilirubinaccumulates.
TheCharcottriadofsevererightupperquadranttendernesswithjaundiceandfever
ischaracteristicofascendingcholangitis.
Acutegallstonepancreatitisisoftencharacterizedbyepigastrictenderness.In
severecases,retroperitonealhemorrhagemayproduceecchymosesoftheflanks
andperiumbilicalecchymoses(CullensignandGreyTurnersign).

Complicationsofgallbladderstones
Acutecholecystitisoccurswhenpersistentstoneimpactioninthecysticductcauses
thegallbladdertobecomedistendedandprogressivelyinflamed.Patients
experiencethepainofbiliarycolic,but,insteadofresolvingspontaneously,thepain
persistsandworsens.
Overgrowthofcolonizingbacteriainthegallbladderoftenoccurs,and,insevere
cases,accumulationofpusinthegallbladder,termedgallbladderempyema,occurs.
Thegallbladderwallmaybecomenecrotic,resultinginperforationand
pericholecysticabscess.Acutecholecystitisisconsideredasurgicalemergency,
althoughpainandinflammationmaysubsidewithconservativemeasures,suchas
hydrationandantibiotics.
Chronically,gallstonesmaycauseprogressivefibrosisofthegallbladderwalland
lossofgallbladderfunction,termedchroniccholecystitis.Thepathogenesisofthis
complicationisnotcompletelyunderstood.Repeatedattacksofacutecholecystitis
mayplayarole,asmaylocalizedischemiaproducedbypressureofstonesagainst
thegallbladderwall.Thechronicallyfibroticgallbladdermaybecomeshrunkenand
adherenttoadjacentviscera.
Gallbladderadenocarcinomaisanuncommoncancerthatusuallydevelopsinthe
settingofgallstonesandchroniccholecystitis.Gallbladdercancerscommonlyinvade
theadjacentliverandcommonbileduct,producingjaundice.Theprognosisispoor
unlessthecancerislocalizedtothegallbladder,inwhichcasecholecystectomymay
becurative.
Occasionally,alargestonemayerodethroughthewallofthegallbladderintoan
adjacentviscus(typicallytheduodenum),producingacholecystoentericfistula.The
stone,ifsufficientlylarge,mayobstructthesmallintestine,usuallyatthelevelof
theileum,aphenomenontermedgallstoneileus.

Complicationsofstonesinthecommonbileduct
Gallstonesareinitiallyretainedinthegallbladderbythespiralvalvesofthecystic
duct.Followingepisodesofgallstoneimpactioninthecysticduct,thesevalvesmay
becomeobliteratedandstonesmaypassintothecommonbileduct.Patientswho
havepassedonestonetendtopassmorestonesoverthesubsequentmonths.
Stonesinthecommonbileductmaybeasymptomatic,but,morecommonly,they
impactdistallyintheampullaofVater.Thismayproducebiliarycolic
indistinguishablefromthatcausedbycysticductstones.Becauseimpactionof
commonbileductstonesoccludestheflowofbilefromthelivertotheintestine,
pressurerisesintheintrahepaticbileducts,leadingtoincreasedliverenzymesand
jaundice.
Bacterialovergrowthinstagnantbileaboveanobstructingcommonductstone
producespurulentinflammationoftheliverandbiliarytree,termedascending
cholangitis.CharacteristicfeaturesincludetheCharcottriadoffever,jaundice,and
rightupperquadrantpain.Patientsmayrapidlydevelopsepticshockunlessductal
obstructionisrelieved.
AstoneimpactedintheampullaofVatermaytransientlyobstructthepancreatic
duct,leadingtoinsituactivationofpancreaticproteasesandtriggeringanattackof
acutepancreatitis.Pancreaticpainisdifferentfrombiliarypain.Thepainislocated
intheepigastricandmidabdominalareasandissharp,severe,continuous,and
radiatestotheback.Nauseaandvomitingarefrequentlypresent,andasimilar
previousepisodeisreportedbyapproximately15%patients.
Stoneimpactioninthedistalcommonbileductisoftenrelievedspontaneously
withinhourstodaysbypassageofthestoneintotheintestine.

Othercomplications
Inflammationfromchroniccholelithiasismayresultinfusionofthegallbladderto
theextrahepaticbiliarytree,causingMirizzisyndrome.Alternatively,afistulainto
theintestinaltractmayform,causinggallstoneileus. [9]
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
DouglasMHeuman,MD,FACP,FACG,AGAFChiefofHepatology,HunterHolmesMcGuireDepartmentof
VeteransAffairsMedicalCenterProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,

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Gallstones(Cholelithiasis)ClinicalPresentation:History,PhysicalExamination

VirginiaCommonwealthUniversitySchoolofMedicine
DouglasMHeuman,MD,FACP,FACG,AGAFisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofPhysicians,AmericanGastroenterological
Association
Disclosure:Receivedgrant/researchfundsfromNovartisforotherReceivedgrant/researchfundsfromBayerfor
otherReceivedgrant/researchfundsfromOtsukafornoneReceivedgrant/researchfundsfromBristolMyers
SquibbforotherReceivednonefromScynexisfornoneReceivedgrant/researchfundsfromSalixforother
Receivedgrant/researchfundsfromMannKindforother.
Coauthor(s)
JeffAllen,MDAssistantProfessor,DepartmentofSurgery,UniversityofLouisville
Disclosure:Nothingtodisclose.
AnastasiosAMihas,MD,DMSc,FACP,FACGProfessor,DepartmentofMedicine,Divisionof
Gastroenterology,VirginiaCommonwealthUniversitySchoolofMedicineConsultingStaff,Virginia
CommonwealthUniversityHospitalsandClinicsChiefofGIClinicalResearch,DirectorofGIOutpatientService,
AssociateDirectorofHepatology,HunterHolmesMcGuireVeteransAffairsMedicalCenter
AnastasiosAMihas,MD,DMSc,FACP,FACGisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeof
Physicians,AmericanGastroenterologicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,Sigma
Xi,SouthernSocietyforClinicalInvestigation,AmericanFederationforClinicalResearch,Gastroenterology
ResearchGroup
Disclosure:Nothingtodisclose.
ChiefEditor
JulianKatz,MDClinicalProfessorofMedicine,DrexelUniversityCollegeofMedicine
JulianKatz,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanGeriatricsSociety,
AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,AmericanSocietyofLaw,
Medicine&Ethics,AmericanTraumaSociety,AssociationofAmericanMedicalColleges,PhysiciansforSocial
Responsibility
Disclosure:Nothingtodisclose.
Acknowledgements
FirassAbiad,MDHeadofDivision,GeneralandLaparoscopicSurgery,SpecializedMedicalCenterHospital,
SaudiArabia
Disclosure:Nothingtodisclose.
BSAnand,MDProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,BaylorCollegeof
Medicine
BSAnand,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiver
Diseases,AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,andAmerican
SocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
DavidEricBernstein,MDDirectorofHepatology,NorthShoreUniversityHospitalProfessorofClinical
Medicine,AlbertEinsteinCollegeofMedicine
DavidEricBernstein,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyof
LiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,American
GastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirector,EmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeof
EmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanThoracic
Society,ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
DavidFMBrown,MDAssociateProfessor,DivisionofEmergencyMedicine,HarvardMedicalSchoolVice
Chair,DepartmentofEmergencyMedicine,MassachusettsGeneralHospital
DavidFMBrown,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
PhysiciansandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
WilliamKChiang,MDAssociateProfessor,DepartmentofEmergencyMedicine,NewYorkUniversitySchool
ofMedicineChiefofService,DepartmentofEmergencyMedicine,BellevueHospitalCenter
WilliamKChiang,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofClinicalToxicology,
AmericanCollegeofMedicalToxicology,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AlfredCuschieri,MD,ChM,FRSE,FRCS,Head,Professor,DepartmentofSurgeryandMolecularOncology,
UniversityofDundee,UK
Disclosure:Nothingtodisclose.
ImadSDandan,MDConsultingSurgeon,DepartmentofSurgery,TraumaSection,ScrippsMemorialHospital

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Gallstones(Cholelithiasis)ClinicalPresentation:History,PhysicalExamination

ImadSDandan,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheSurgeryof
Trauma,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanTraumaSociety,California
MedicalAssociation,andSocietyofCriticalCareMedicine
Disclosure:Nothingtodisclose.
DavidGreenwald,MDAssociateProfessorofClinicalMedicine,FellowshipProgramDirector,Departmentof
Medicine,DivisionofGastroenterology,MontefioreMedicalCenter,AlbertEinsteinCollegeofMedicine
DavidGreenwald,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
Gastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanSociety
forGastrointestinalEndoscopy,andNewYorkSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
FayeMaryannLee,MDStaffPhysician,DepartmentofEmergencyMedicine,NewYorkUniversity/Bellevue
HospitalCenter
FayeMaryannLee,MDisamemberofthefollowingmedicalsocieties:PhiBetaKappa
Disclosure:Nothingtodisclose.
SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,Vanderbilt
University
SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AssaadMSoweid,MD,FASGE,FACGAssociateProfessorofClinicalMedicine,Endosonographyand
AdvancedTherapeuticEndoscopy,Director,EndoscopyBronchoscopyUnit,DivisionofGastroenterology,
DepartmentofInternalMedicine,AmericanUniversityofBeirutMedicalCenter,Lebanon
AssaadMSoweid,MD,FASGE,FACGisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Gastroenterology,AmericanCollegeofPhysicians,AmericanCollegeofPhysiciansAmericanSocietyofInternal
Medicine,AmericanGynecologicalandObstetricalSociety,andAmericanMedicalAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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