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