Cholelithiasis and cholecystitis

De villa dennis fernando M. Level IV

A Cause For Pain

Background
j Presence of gallstones in the gallbladder. j Spectrum ranges from asymptomatic, colic,

cholangitis, choledocholithiasis, cholecystitis j Colic is a temporary blockage, cholecystitis is inflammation from obstruction of CBD or cystic duct, cholangitis is infection of the biliary tree.

.Pathophysiology j Three types of stones. j Cholesterol stones most common. phospholipids in a fine balance. j Formation of each types is caused by crystallization of bile. cholesterol. j Bile consists of lethicin. pigment. bile acids. j Impaired motility can predispose to stones. mixed.

j Pigment stones (15%) are from calcium bilirubinate. or be independent of it. parasitic infections. It may be a first step in stones. Diseases that increase RBC destruction will cause these. .Pathophysiology j Sludge is crystals without stones. Also in cirrhotic patients.

Harvest Time .

Morbidity/Mortality j Every year 1-3% of patients develop symptoms. . j Morbidity and mortality is associated only with symptomatic stones. j Asymptomatic GS are not associated with fatalities.

In addition Asians with stones are more likely to have pigmented stones than other populations. . j High in Pima Indians (75% of elderly). j African descent with Sickle Cell Anemia.Race j Highest in fair skinned people of northern European descent and in Hispanic populations.

. j Pregnant women more likely to have symptoms. j Women with multiple pregnancies at higher risk j Oral contraceptives. estrogen replacement tx. Etiology may be secondary to variations in estrogen causing increased cholesterol secretion. and progesterone causing bile stasis.Sex j More common in women.

Age j It is uncommon for children to have gallstones. its more likely that they have congenital anomalies. If they do. . or hemolytic pigment stones. j Incidence of GS increases with age 1-3% per year. biliary anomalies.

and with complications (cholecystitis. j Most (60-80%) are asymptomatic j A history of epigastric pain with radiation to shoulder may suggest it. CBD stones).History j 3 clinical stages: asymptomatic. symptomatic. . cholangitis. j A detailed history of pattern and characteristics of symptoms as well as US make the diagnosis.

severe symptoms develop in 3-9%. fatty food intolerance occur in similar frequencies in patients without gallstones. bloating. j Indigestion. . j Once symptoms occur. and a cholecystectomy rate of 3-8% per year. and are not cured with cholecystectomy. with complications in 1-3% per year.History j Most patients develop symptoms before complications.

. however visceral pain and GB wall distension may be only in the epigastric area. often waking patient at night.History j Best definition of colic is pain that is severe in epigastrium or RUQ that last 1-5 hrs. Small stones more symptomatic. j In classic cases pain is in the RUQ. j Once peritoneum irritated. localizes to RUQ.

including cholangitis. cholecystitis. j Murphy¶s sign . alert you to more serious infections.Physical j Vital signs and physical findings in asymptomatic cholelithiasis are completely normal. j Fever. hypotension. tachycardia.

j High fat diet j Obesity j Rapid weight loss.Causes j Fair. Ileal disease. TPN. female. j Diabetics have more complications. fat. j Increases with age. fertile of course. j Hemolytics . alcoholism. NPO.

MI. SBO j Pancreatitis. hepatitis j IBD. pneumonia . cholelithiasis j Diverticulitis j Gastroenteritis.Differentials j AAA j Appendicitis j Cholangitis. renal colic.

ALT Bili. and showed no difference in WBC.Workup j Labs with asymptomatic cholelithiasis and biliary colic should all be normal. in patients diagnosed and those without. AST. j Study by Singer et al examined utility of labs with chole diagnosed with HIDA. . elevated LFTS may be helpful in diagnosis of acute cholecystitis. but normal values do not rule it out. and Alk Phos. j WBC.

000 may indicate perforation or gangrene. . AST.Workup j Elevated WBC is expected but not reliable. only 60% of patients with cholecytitis had a WBC greater than 11. j ALT. A WBC greater than 15.000. j In retrospective study. AP more suggestive of CBD stones j Amylase elevation may be GS pancreatitis.

. surrounding organs.Imaging Studies j US and Hida best. j X-rays: 15% stones are radiopaque. Plain x-rays. j CT: for complications. CT scans ERCP are adjuncts. Misses 20% of GS. Air in biliary tree. Get if diagnosis uncertain. porcelain GB may be seen. emphysematous GB wall. ductal dilatation.

CT Scan .

Plain Films .

j Wall thickening (2-4mm) false positives! j Distension j Pericholecystic fluid. 80% specific for cholecystitis. It is 98% sensitive and specific for simple stones. .Imaging j Ultrasound is 95% sensitive for stones. j Dilated CBD(7-8mm). sonographic Murphy¶s.

Ultrasound .

Ultrasound .

j If GB visualized later it may point to chronic cholecystitis. j CBD obstruction appears as non visualization of small intestine. j 94% sensitive.Imaging j Hida scan documents cystic duct patency. j False positives. . 85% specific j GB should be visualized in 30 min. high bilirubin.

cholangitis. pancreatitis. j Complications include bleeding. .Imaging j ERCP is diagnostic and therapeutic. j Do when CBD dilated and elevated LFTs. j Provides radiographic and endoscopic visualization of biliary tree. perforation.

ERCP .

with or without fever.Emergency Department Care j Suspect GB colic in patients with RUQ pain of less than 4-6h duration radiating to back. j Consider acute cholecystits in those with longer duration of pain. Elderly and diabetics do not tolerate delay in diagnosis and can proceed to sepsis. .

and monitoring. EKG. .Emergency Department Care j After assessment of ABCs. j Primary goal of ED care is diagnosis of acute cholecystitis with labs. perform standard IV. US. include cultures if febrile. Once diagnosed. Send labs while IV placed. hospitalization usually necessary. and or Hida. pulse oximetry. Some treated as OP.

j Replace volume with IVF. . A courtesy call to surgery may give them time to examine without narcotics.NGT. +/. j Administer pain control early. consider a bedside US to exclude AAA and to assist in diagnosis of acute cholecystitis. NPO.Emergency Department Care j In patients who are unstable or in severe pain.

either medicine or surgery may admit the patients for care. .Consults j Historically cholecystits was operated on emergently which increased mortality. j Get GI involved early if suspect CBD obstruction. and depending on the institution. j Surgical consult is appropriate.

compazine). (20mg IM q4-6). j Antibiotics (Zosyn 3. enterococci. . Enterobacter(34%). Klebsiella(54%). j Demerol 25-75mg IV/IM q3 j Antiemetics (phenergan. group D strep.375g IV q6) need to cover Ecoli(39%).Medications j Anticholinergics such as Bentyl (dicyclomine hydrochloride)to decrease GB and biliary tree tone.

5% convert to open. or cholecystectomy. Unstable patients may need more urgent interventions with ERCP. j Lap chole very effective with few complications (4%). percutaneous drainage. In acute setting up to 50% open. .Further Inpatient Care j Cholecystectomy can be performed after the first 24-48h or after the inflammation has subsided.

Laparoscopic Cholecystectomy .

Laparoscopic Cholecystectomy .

j Next day follow-up visit. normal CBD. j Discharge on oral antibiotics.Further Outpatient Care j Afebrile. pain meds. j No markedly abnormal labs. no pericholecystic fluid. normal VS j Minimal pain and tenderness. j No underlying medical problems. .

j Hepatitis j Choledocholithiasis .Complications j Cholangitis. sepsis j Pancreatitis j Perforation (10%) j GS ileus (mortality 20% as diagnosis difficult).

j Gangrenous GB 25% mortality. j Emphysematous GB mortality is 15% j Perforation of GB occurs in 3-15% with up to 60% mortality.Prognosis j Uncomplicated cholecystitis as a low mortality. .

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