Cholelithiasis

Anatomy
• Gallstones usually form in the gallbladder;
however, they also may form anywhere there is
bile; in the intrahepatic, hepatic, common bile,
and cystic ducts.
• Gallstones also may move about within bile, for
example, from the gallbladder into the cystic or
common duct.
• Bile consists of lethicin,bile acids, phospholipids
in fine balance with cholestrol.
 Pathophysiology
• Three types of stones: cholesterol, pigment, mixed.
• Formation of each types is caused by crystallization of bile.
• Impaired motility can predispose to stones
• Sludge is crystals without stones. It may be a first step in stones, or
be independent of it.
• Cholesterol stones most common(80%).
• Pigment stones (15%) are from calcium bilirubinate. Diseases that
increase RBC destruction will cause these : sickle cell disease and
thalassemia.
– Also in cirrhotic patients, parasitic infections.
• There are two types of pigment gallstones
1) Black pigment gallstones, and
2) Brown pigment gallstones(The bacteria alter)
Harvest Time
 Etiology
• More common in women. Etiology may be secondary
to variations in estrogen causing increased cholesterol
secretion, and progesterone causing bile stasis.
• Women with multiple pregnancies at higher risk
• Oral contraceptives, estrogen replacement tx
• Highest in fair skinned people
• If in children, its more likely that they have congenital
anomalies, biliary anomalies, or hemolytic pigment
stones.
• Incidence of GS increases with age 1-3% per year.
 Clinical presentation
• 3 clinical stages: asymptomatic, symptomatic, and with complications
(cholecystitis, cholangitis, CBD stones).
• Most (60-80%) are asymptomatic
• A history of epigastric pain with radiation to shoulder may suggest it. Indigestion,
bloating, fatty food intolerance
• Once symptoms occur, severe symptoms develop in 3-9%, with complications in 1-
3% per year, and a cholecystectomy rate of 3-8% per year.
• Biliary colic is a very specific type of pain, occurring as the primary or only
symptom in 80% of people with gallstones who develop symptoms.
– It occurs when the extrahepatic ducts-cystic, hepatic or common bile-are suddenly blocked
by a gallstone.
– It lasts for 15 minutes to 4-5 hours. If the pain lasts more than 4-5 hours, it means that a
complication - usually cholecystitis - has developed.
– The pain usually is severe
– Usually below the sturnum but can occur below the ribs
– Occasionally may be felt in the back at the lower tip of the scapula on the right side.
– Rarely, the pain may be felt beneath the sternum and be mistaken for angina or a heart
attack.
 Physical
• Vital signs and physical findings in
asymptomatic cholelithiasis are completely
normal.
• Fever, tachycardia, hypotension, alert you to
more serious infections, including cholangitis,
cholecystitis.
• Murphy’s sign
 Complications of gallstones
Cholecystitis
• Cholecystitis means inflammation of the gallbladder.
• Caused by sudden obstruction of the ducts by a gallstone, usually the
cystic duct which causes the wall of the gallbladder to begin secreting
fluid and for unclear reasons, inflammation sets in b/se of Chemical
irritants in the bile
• Lysolecithin
• Prostaglandins
• over time the bile and gallbladder become infected with bacteria
that travel through the ducts from the intestine.
• Bacterial pathogens present in 50-80% of cases
– Most common E.coli and Klebsiella (70%)
• 90% of acute cholecystitis cases due to gallstones
• Acute Cholecystitis is the initial presentation of symptomatic
gallstones in 15% - 20% of patients
 Complications of gallstones
Acute cholecystitis symptoms
• In fact, cholecystitis may begin with an episode of
biliary colic.
• RUQ Pain—constant and aggravated by
movement
• Fever
• +/- Jaundice
• Positive Murphy’s Sign
• Leukocytosis
 Complications of gallstones
Management of Acute Cholecystitis
• Supportive care with IV Fluids, bowel rest, &
Antibiotics
• Almost half of patients have positive bile cultures
• E. Coli is most common organism
• Antibiotic choice: Ampicillin + Aminoglycoside or
3rd generation cephalosporin
• NSAIDs may improve course of acute cholecystitis
• SURGERY is the only definitive treatment
 Complications of gallstones
• Timing of Surgery
• Early surgery = Within 72 hours of admission or onset
of symptoms
• Delayed surgery = Supportive care only followed by
discharge and readmission in 6-12 weeks for surgery
• Even without antibiotics, cholecystitis often
resolves.
• As with biliary colic, movement of the gallstone
out of the cystic duct and back into the
gallbladder relieves the obstruction and allows
the inflammation to resolve
 Complications of gallstones
Cholangitis
• Cholangitis is a condition in which bile in the
common, hepatic, and intrahepatic ducts
becomes infected.
• Like cholecystitis, the infection spreads through
the ducts from the intestine after the ducts
become obstructed by a gallstone.
• Patients with cholangitis are very sick with a high
fever and elevated white blood cell counts.
• Cholangitis may result in an abscess within the
liver or sepsis.
 Complications of gallstones
Other complications
• Gangrene
• Jaundice
• Pancreatitis
• Sepsis
 Workup
• Labs with asymptomatic cholelithiasis and biliary colic
should all be normal.
• WBC, elevated LFTS may be helpful in diagnosis of acute
cholecystitis, but normal values do not rule it out.
• In retrospective study, only 60% of patients with
cholecystitis had a WBC greater than 11,000. A WBC
greater than 15,000 may indicate perforation or
gangrene.
• SGOT, SGPT,ALP more suggestive of CBD stones
• Amylase elevation may be GS pancreatitis
 Imaging Studies
• US , Hida best, Plain x-rays, CT scans ,ERCP are
adjuncts.
• X-rays: 15% stones are radiopaque, porcelain
GB may be seen. Air in biliary tree,
emphysematous GB wall.
• CT: for complications, ductal dilatation,
surrounding organs. Misses 20% of GS. Get if
diagnosis uncertain.
Plain Films
 Imaging
• Ultrasound is 95% sensitive for stones, 80%
specific for cholecystitis. It is 98% sensitive
and specific for simple stones.
• Wall thickening (2-4mm) false positives!
• Distension
• Pericholecystic fluid, sonographic Murphy’s.
• Dilated CBD(7-8mm).
• 50% of CBD stones
 Imaging
• For a HIDA scan, a radioactive chemical is
injected intravenously into the patient.
• The radioactive chemical is removed from the
blood by the liver and secreted into the bile.
• The chemical then disperses everywhere that
the bile goes-into the bile ducts, the
gallbladder, the intestine, and any place else
that bile goes.
 Imaging
• ERCP( Endoscopic retrograde
cholangiopancreaticography) is diagnostic and
therapeutic.
• Provides radiographic and endoscopic
visualization of biliary tree.
• Do when CBD dilated and elevated LFTs.
• Complications include bleeding, perforation,
pancreatitis, cholangitis.
 Emergency Department Care
• Elderly and diabetics do not tolerate delay in
diagnosis and can proceed to sepsis.
• Primary goal of ED care is diagnosis of acute
cholecystitis with labs, US, and or Hida. Once
diagnosed, hospitalization usually necessary.
Some treated as OutPatient.
• Replace volume with IVF, NPO, +/- NGT.
• Administer pain control early.
 Further Inpatient Care
• Cholecystectomy can be performed after the
first 24-48h or after the inflammation has
subsided. Unstable patients may need more
urgent interventions with ERCP, percutaneous
drainage, or cholecystectomy.
• Lap chole very effective with few
complications (4%). 5% convert to open. In
acute setting up to 50% open.
 Further Outpatient Care
• Afebrile, normal VS
• Minimal pain and tenderness.
• No markedly abnormal labs, normal CBD, no
pericholecystic fluid.
• No underlying medical problems.
• Next day follow-up visit.
• Discharge on oral antibiotics, pain meds.
 Prognosis
• Uncomplicated cholecystitis has a low
mortality.
• Emphysematous GB mortality is 15%
• Perforation of GB occurs in 3-15% with up to
60% mortality.
• Gangrenous GB 25% mortality.
 Obstructive jaundice
• Common bile duct is about 7 to 11 cm in length
and 5 to 10 mm in diameter
• Biliary obstruction refers to the blockage of any
duct that carries bile from the liver to the
gallbladder or from the gallbladder to the small
intestine.
• Excretion is the rate-limiting step and is usually
impaired to the greatest extent.
• As a result, conjugated bilirubin predominates in
the serum.
 Pathophysiology
• Total serum bilirubin values are normally 0.2-1.2 mg/dL.
• Jaundice may not be clinically recognizable until levels are at least 3
mg/dL.
• Conjunctival icterus is generally a more sensitive sign of
hyperbilirubinemia than generalized jaundice.
• Urine bilirubin is normally absent. When it is present, only
conjugated bilirubin is passed into the urine. This may be evidenced
by dark-colored urine seen in patients with obstructive jaundice or
jaundice due to hepatocellular injury.
• However, reagent strips are very sensitive to bilirubin, detecting as
little as 0.05 mg/dL.
• Urine bilirubin may be found before serum bilirubin reaches levels
high enough to cause clinical jaundice
• The lack of bilirubin in the intestinal tract is responsible for the pale
stools typically associated with biliary obstruction
• The cause of itching (pruritus) may be related to the accumulation
of bile acids in the skin.
 Clinical presentation

History
• Patients commonly complain of pale stools, dark
urine, jaundice, and pruritus.  
• The following considerations are important:
– Patients' ages and associated conditions
– The presence or absence of pain  
– The location and characteristics of the pain  
– The acuteness of the symptoms  
– The presence of systemic symptoms (eg, fever, weight
loss)
 Clinical presentation (cont)

– Symptoms of gastric stasis (eg, early satiety, vomiting,

belching)  
– History of anemia  
– Previous malignancy  
– Known gallstone disease  
– Gastrointestinal bleeding  
– Hepatitis
– Previous biliary surgery  
– Diabetes or diarrhea of recent onset
 Clinical presentation (cont)
Physical
• Upon physical examination, the patient may
display signs of jaundice (skin and icterus).  
• When the abdomen is examined, the gallbladder
may be palpable (Courvoisier sign). This may be
associated with underlying pancreatic
malignancy.
• Also, look for signs of weight loss, adenopathies,
and occult blood in the stool, suggesting a
neoplastic lesion
 Clinical presentation (cont)
• Note the presence or absence of ascites and
collateral circulation associated with cirrhosis.  
• A high fever and chills suggest a coexisting
cholangitis.  
• Abdominal pain may be misleading; some
patients with CBD calculi have painless
jaundice, whereas some patients with hepatitis
have distressing pain in the right upper
quadrant. Malignancy is more commonly
associated with the absence of pain and
tenderness during the physical examination.  
• Excoriations suggest prolonged cholestasis or
high-grade biliary obstruction.
 Causes
• Obstruction to the flow of bile may occur within the
ducts or secondary to external compression.
• Extrahepatic causes may be further subdivided into
those that are intraductal and those that are
extraductal.
– Intraductal causes include neoplasms, stone disease,
biliary stricture, parasites, primary sclerosing cholangitis
(PSC), AIDS-related cholangiopathy, and biliary
tuberculosis.  
– Extraductal obstruction caused by external compression of
the biliary ducts may be secondary to neoplasms,
pancreatitis, or cystic duct stones with subsequent
gallbladder distension.
• Overall, gallstones are the most common cause of
biliary obstruction.
• CBD stones are found in 6 to 12% of patients with
stones in the gallbladder
• majority of ductal stones are formed within the
gallbladder and migrate down the cystic duct to the
common bile duct. These are classified as secondary
common bile duct stones
• Primary stones are formed in the bile ducts.
• Biliary colic that recurs at any point after a
cholecystectomy should prompt evaluation for
possible choledocholithiasis.
• Mirizzi syndrome is the presence of a stone impacted in the
cystic duct or the gallbladder neck, causing inflammation and
external compression of the common hepatic duct and thus
biliary obstruction.
• Secondary stones are usually cholesterol stones,
whereas the primary stones are usually of the
brown pigment type
• Causes of biliary stasis that lead to the
development of primary stones include biliary
stricture, papillary stenosis, tumors, or other
(secondary) stones
• Pain caused by a stone in the bile duct is very
similar to that of biliary colic caused by impaction
of a stone in the cystic duct
• Of biliary strictures, 95% are due to surgical
trauma and 5% are due to external injury to the
abdomen or pancreatitis or erosion of the duct
by a gallstone.
• Stone disease is the most common cause of
biliary strictures in patients who have not
undergone an operation.
• A tear in the duct causes bile leakage and
predisposes the patient to a localized infection. In
turn, this accentuates scar formation and the
ultimate development of a fibrous stricture.
• Of parasitic causes, adult Ascaris lumbricoides can
migrate from the intestine up through the bile
ducts, thereby obstructing the extrahepatic ducts.
– Eggs of certain liver flukes (eg, Clonorchis sinensis,
Fasciola hepatica) can obstruct the smaller bile ducts
within the liver, resulting in intraductal cholestasis.
– This is more common in Asian countries.
• Biliary tuberculosis is extremely rare.
• Biliary obstruction associated with pancreatitis is
observed most commonly in patients with dilated
pancreatic ducts due to either inflammation with
fibrosis of the pancreas or a pseudocyst.
• PBC is a chronic, progressive, nonsuppurative, granulomatous destruction
of the intrahepatic ducts.
• PBC, an autoimmune destruction of small hepatic ducts, is more common
in women than in men.
• It generally manifests as a progressive obstructive jaundice and is most
readily diagnosed based on findings from endoscopic retrograde
cholangiopancreatography (ERCP).
• PSC is most common in men aged 20-40 years, and the cause is unknown.
• PSC is commonly associated with inflammatory bowel disease (IBD), most
commonly in patients with pancolitis.
• IBD (the vast majority being ulcerative colitis) is present in 60-80% of
patients with PSC, and PSC is found in approximately 3% of patients with
ulcerative colitis.
 Complications

• The complications of cholestasis are

proportional to the duration and intensity of
the jaundice.
• High-grade biliary obstruction begins to cause
cell damage after approximately 1 month and,
if unrelieved, may lead to secondary biliary
cirrhosis.
 Complications (cont)
• Acute cholangitis is another complication
associated with obstruction of the biliary tract
• Is the most common complication of a
stricture, most often at the level of the CBD.
• Bile normally is sterile.
• In the presence of obstruction to flow, stasis
favors colonization and multiplication of
bacteria within the bile.
 Complications (cont)
• Concomitant increased intraductal pressure can
lead to the reflux of biliary contents and
bacteremia, which can cause septic shock
• medical treatment of the patient with cholangitis
serves only as a temporary measure.
• Long-term relief of the biliary obstruction,
whether it be surgical, percutaneous, or
endoscopic, is necessary to prevent an adverse
outcome.
 Complications (cont)
• Failure of bile salts to reach the intestine
results in fat malabsorption with steatorrhea.
• Fat-soluble vitamins A, D, E, and K are not
absorbed, resulting in vitamin deficiencies
which results in coagulation factor deficiency
• Disordered hemostasis with an abnormally
prolonged PT may further complicate the
course of these patients.
 Laboratory Studies

• Serum bilirubin: Regardless of the cause of

cholestasis, serum bilirubin values (especially
direct) are usually elevated.
• The degree of hyperbilirubinemia cannot help
reliably distinguish between the causes of
obstruction.
• Alkaline phosphatase (ALP): is markedly elevated
in persons with biliary obstruction. To determine
whether the enzyme is likely to be of hepatic
origin, measure gamma-glutamyl transpeptidase
(GGT) or 5-prime-nucleotidase.
 Laboratory Studies (cont)
• Serum transaminases:
– Levels of liver enzymes are usually only moderately
elevated in patients with cholestasis.
– occasionally may be markedly increased, especially if
cholangitis is present.
• Prothrombin time (PT): prolonged because of
malabsorption of vitamin K.
– Correction of the PT by parenteral administration of
vitamin K may help distinguish hepatocellular failure from
cholestasis.
– Little or no improvement occurs in patients with
parenchymal liver disease.
 Laboratory Studies (cont)
• Hepatitis serology:
• Urine bilirubin:
 Imaging Studies
• Plain radiographs are of limited utility to help detect abnormalities in the
biliary system.
• Frequently, calculi are not visualized because few are radiopaque.
• Ultrasonography (US) is the least expensive, safest, and most sensitive
technique for visualizing the biliary system, particularly the gallbladder.
– Current accuracy is close to 95%.
– Extrahepatic obstruction is suggested by the presence of dilated bile
ducts, but the presence of normal bile ducts does not exclude
obstruction.
– Visualization of the pancreas, kidney, and blood vessels is also possible.
– US is not as useful for CBD stones (bowel gas may obscure visualization
of the CBD). Only 50%
– The cystic duct is also poorly imaged.
– It is less useful diagnostically in individuals who are obese.
• Traditional computed tomography (CT) scan is usually considered
more accurate than US to determine the specific cause and level of
obstruction.
– The addition of intravenous contrast helps to differentiate and define
vascular structures and the biliary tract.
– CT scan has limited value in helping diagnose CBD stones because
many of them are radiolucent and CT scan can only image calcified
stones.
– It is also less useful in the diagnosis of cholangitis because the findings
that specifically suggest bile duct infection (increased attenuation due
to pus, bile duct wall thickening, and gas) are seen infrequently.
– Useful to visualize other tumor
– Lastly, CT scan is expensive and involves exposure to radiation, both of
which lessen the routine use CT scans compared to US examinations.
• Spiral (helical) CT scan improves biliary tract imaging by
providing several overlapping images in a shorter time than
traditional CT scan and by improving resolution by reducing the
presence of respiratory artifacts.
– CT cholangiography by the helical CT technique is used most
often to image the biliary system and makes possible
visualization of radiolucent stones and other biliary
pathology.
– Limitations of helical CT cholangiography include reactions to
the contrast, which are becoming less frequent.
– As serum bilirubin levels increase, the ability to visualize the
biliary tree diminishes and the ability to fully delineate
tumors decreases.
• Magnetic resonance cholangiopancreatography
(MRCP) is a noninvasive way to visualize the
hepatobiliary tree.
• MRCP provides a sensitive noninvasive method of
detecting biliary and pancreatic duct stones,
strictures, or dilatations within the biliary system.
• ERCP is an outpatient procedure that combines
endoscopic and radiologic modalities to visualize
both the biliary and pancreatic duct systems.
• Endoscopically, the ampulla of Vater is identified
and cannulated.
• A contrast agent is injected into these ducts, and
x-ray images are taken to evaluate their caliber,
length, and course.
• It is especially useful for lesions distal to the
bifurcation of the hepatic ducts.
• Besides being a diagnostic modality, ERCP has a
therapeutic application because obstructions can
potentially be relieved by the removal of stones,
sphincterotomy, and the placement of stents and
drains.
– Complications of ERCP include pancreatitis,
perforation, biliary peritonitis, sepsis, hemorrhage,
and adverse effects from the dye and the drug used
to relax the duodenum.
– The risk of any complication is less than 10%.
– Severe complications occur in less than 1%.
– The sensitivity and specificity of ERCP are 89-98% and
89-100%, respectively.
– ERCP is still considered the criterion standard for
imaging the biliary system, particularly if therapeutic
intervention is planned.
• Percutaneous transhepatic cholangiogram (PTC)
is performed by a radiologist using fluoroscopic
guidance.
• The liver is punctured to enter the peripheral
intrahepatic bile duct system.
• An iodine-based contrast medium is injected into
the biliary system and flows through the ducts.
• Obstruction can be identified on the fluoroscopic
monitor.
 Treatment
• Obstructive Jaundice:
– Should r/o ascending cholangitis, ABC/resuscitate
• For cholangitis: IVF, IV Antibiotics, Decompression
– Stones (remove stones vs stent vs drainage)
• Done via ERCP or PTC or open (surgery)
– Benign stricture (stent vs drainage catheter)
– Cancer (Stent vs drainage +/- resect the CA)
• The key principle is decompression, either
externally(drainage) or internally(stenting) the
duct open to allow better drainage