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Updated: Aug 12 2022



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  • Snapshot
    • A 50-year-old woman presents to her family medicine physician's office due to recurrent abdominal pain. She reports that this often occurs after a meal out, or when she takes her children to get burgers at a fast food chain. She reports that it is primarily in her right upper quadrant, and the pain episodes resolve after an hour. She has a history of hypertension but is otherwise healthy. On physical exam, there are no remarkable findings. She is sent for an ultrasound to evaluate for gallstones.
  • Introduction
    • Clinical definition
      • cholelithiasis
        • stones in gallbladder are cholesterol or pigment stones
    • Epidemiology
      • demographics
        • female > male
        • adults
      • risk factors
        • cholesterol stones (most common)
          • F’s
            • Fat
            • Female
            • Forty
            • Fertile
          • impaired gallbladder emptying
            • total parenteral nutrition
            • starvation
            • diabetes
          • biliary stasis
            • rapid weight loss
          • Native American heritage
        • pigment stones
          • brown
            • result of common bile duct infection
            • result of bacterial-mediated release of beta-glucuronidase leading to formation of unconjugated bilirubin and glucoronic acid
            • unconjugated bilirubin levels rise and result in brown pigmented stones
          • black
            • composed of calcium bilirubinate
            • result of ↑ liver excretion of bilirubin secondary to chronic RBC degradation
    • Pathogenesis
      • cholesterol saturation can cause impaired gallbladder motility
      • gallstones can lead to mechanical obstruction of biliary tract and cause bacterial overgrowth
    • Associated conditions
      • acute cholecystitis
      • ascending cholangitis
      • acute pancreatitis
      • gallstone ileus
  • Presentation
    • Symptoms
      • cholelithiasis
        • may be asymptomatic
      • biliary colic
        • colicky pain in right upper quadrant
        • may radiate to the right shoulder
        • triggered by fatty or heavy foods
        • episodes self-resolve
  • Imaging
    • Right upper quadrant ultrasound
      • findings
        • gallstones
    • Magnetic resonance cholangiopancreatography (MRCP)
      • indication
        • ultrasound results are equivocal
    • Endoscopic retrograde cholangiopancreatography (ERCP)
      • indication
        • both diagnostic and therapeutic
        • if intervention is indicated
  • Studies
    • Serum labs
      • alkaline phosphatase and bilirubin may be elevated but only mildly
      • amylase
        • to assess for gallstone pancreatitis
  • Differential
    • Peptic ulcer disease
      • distinguishing factors
        • epigastric gnawing pain that may improve with meals
        • ultrasound will show no signs of biliary disease
    • Sphincter of Oddi dysfunction
      • distinguishing factors
        • presents similarly to biliary colic
        • diagnosed with manometry
        • treated with sphincterotomy via ERCP
  • Treatment
    • Conservative
      • supportive care
        • analgesia
          • NSAIDs
        • diet
          • avoid fatty foods that trigger biliary colic
        • rehydration
    • Medical
      • ursodeoxycholic acid
        • indication
          • patients unwilling or contraindicated to undergo cholecystectomy
          • can be used as prophylaxis
          • mechanism
            • dissolves gallstones
    • Surgical
      • elective cholecystectomy
        • indications
          • symptomatic cholelithiasis
          • patients at risk for cholangiocarcinoma
            • Native American heritage
            • porcelain gallbladder
            • gallstone pancreatitis
  • Complications
    • Cholecystitis
    • Secondary infections
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