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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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.GI.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? Review Topic

QID: 101209
1

E. coli infection; beta-glucoronidase release

44%

(32/73)

2

Shigella infection; HMG-CoA reductase release

3%

(2/73)

3

Shigella infection; beta-glucoronidase release

14%

(10/73)

4

Bile supersaturated with cholesterol; beta-glucoronidase release

30%

(22/73)

5

Ascaris lumbricoides infection; bile supersaturated with cholesterol

4%

(3/73)

M1

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