Updated: 9/3/2019

Cholelithiasis

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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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(M1.GI.13.152) A 51-year-old female presents with intermittent right upper quadrant discomfort. The physician suspects she is suffering from biliary colic and recommends surgery. Following surgery, brown stones are removed from the gallbladder specimen. What is the most likely cause of the gallstone coloring?

QID: 101209
1

E. coli infection; beta-glucoronidase release

42%

(47/113)

2

Shigella infection; HMG-CoA reductase release

3%

(3/113)

3

Shigella infection; beta-glucoronidase release

9%

(10/113)

4

Bile supersaturated with cholesterol; beta-glucoronidase release

39%

(44/113)

5

Ascaris lumbricoides infection; bile supersaturated with cholesterol

4%

(4/113)

M 1 D

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