Overview Snapshot A 49-year-old obese Hispanic female presents to a community physician late in the afternoon with progressively worsening yet constant RUQ pain that worsened after eating a fatty meal. She obtains a RUQ ultrasound scan, which reveals the presence of gallstones without pericystic fluid or wall thickening. The physician recommends ibuprofen for pain relief, increased fluid intake, minimal fatty food intake, and follow-up in two days for reevaluation of labs, including the patients bilirubin and amylase levels. Introduction Risk factors for cholesterol stones: Four F's Fat (obesity) Female (estrogen source - OCP) Forty Fertile (multiparity) impaired gallbladder emptying: starvation, diabetes (paresis), TPN rapid weight loss (due to rapid cholesterol mobilization and biliary stasis) terminal ileal resection or disease (e.g., Crohn's) Native American heritage (especially Pima Indians) Risk factors for pigment stones (calcium-based) cirrhosis biliary stasis (strictures, dilation, biliary infection) chronic hemolysis Presentation Symptoms gallstones are common and most are asymptomatic (80%) biliary colic is transient impaction of gallstone in cystic duct without evidence of infection steady, severe dull pain in epigastrium or RUQ for minutes to hours crescendo-decrescendo pattern possible presence of chest pain possible radiation to right scapula or shoulder no systemic signs or peritoneal signs frequently after fatty meal or at night symptoms similar to colic can also be caused by spincter of Oddi dysfunction, which can be diagnosed with spincter manometry and treated with spincerterotomy via ERCP Evaluation Imaging first-line: RUQ ultrasound ERCP (endoscopic retrograde cholangiopancreatography) diagnostic: visualizes upper GI tract, ampullary region, biliary and pancreatic ducts therapeutic: treats common bile duct stones in periampullary region MRCP (magnetic resonance cholangiopancreatography) non-invasive compared to ERCP, but not therapeutic radiograph only valuable if positive because 15-20% of gallstones are radiopaque Labs most important labs for biliary pain total and direct bilirubin levels: for evidence of obstruction amylase: for evidence of gallstone pancreatitis CBC, electrolytes, LFTs Treatment Asymptomatic patients do not require cholecystectomy Pain control, rehydration during colic episode Sphincter of Oddi dysfunction presents similar to acute cholecystitis ERCP with sphincterotomy Elective laparoscopic cholecystectomy no evidence of benefit for delaying surgery patients at risk for cancer should have cholecystectomy Native Americans patients with imaging suggestive of porcelain gallbladder (gallbladder cancer) cholecystectomy for patients with recurrent biliary colic or evidence of pancreatitis