Review Question - QID 218380

This obese, multiparous patient presenting with right upper quadrant abdominal pain that is post-prandial, nausea, vomiting, mild right upper quadrant discomfort to palpation, and normal liver function tests most likely has biliary colic caused by a gallstone. The most common type of gallstone is a cholesterol gallstone, which is caused by high cholesterol saturation in the bile. She additionally has microcytic anemia likely secondary to iron deficiency as a result of her menorrhagia.

Gallstones are typically either cholesterol (common) or pigment stones. Risk factors for cholesterol stones include obesity, female sex, age of around 40 years, and multiparity. High cholesterol saturation in the bile causes the precipitation of cholesterol gallstones. As the gallbladder contracts after a meal (especially after fatty meals), a gallstone may become lodged in the cystic duct, leading to right upper quadrant abdominal pain. When the gallbladder relaxes, the stone dislodges and the pain resolves, typically several hours after beginning. This is termed symptomatic cholelithiasis. Symptomatic cholelithiasis can be diagnosed by ultrasound showing gallstones in a symptomatic patient. Symptomatic cholelithiasis is treated with an elective cholecystectomy.

Gurusamy, Koti, Fusai, and Davidson studied the risks and benefits of early versus delayed laparoscopic cholecystectomy for the treatment of uncomplicated biliary colic. They found limited evidence that laparoscopic cholecystectomy within 24 hours after the diagnosis of biliary colic decreases morbidity. They recommended that further randomized clinical trials be performed to better elucidate this finding.

Incorrect Answers:
Answer 2: Chronic intravascular hemolysis can be a cause of pigmented gallstones. Pigmented gallstones are composed of bilirubin decomposition products, which are the result of red blood cell hemolysis. For example, patients with sickle cell disease have chronic intravascular hemolysis. This presents with recurrent vaso-occlusive episodes leading to severe pain (e.g., in the chest, extremities), autosplenectomy resulting in recurrent infections, and severe anemia. In contrast, this patient has a microcytic anemia which is likely the result of her menorrhagia in the setting of not taking any iron supplementation.

Answer 3: Defective bilirubin glucuronidation is the cause of Gilbert syndrome. Patients with Gilbert syndrome are typically asymptomatic but may present with episodic jaundice during episodes of stress. Since there is increased unconjugated bilirubin in these patients, they are at higher risk of pigmented gallstone disease. However, cholesterol gallstones are more common, especially given that this patient is obese, multiparous, female, and around 40 years of age.

Answer 4: Hypertriglyceridemia is a risk factor for acute pancreatitis. A serum triglyceride level of greater than 1,000 mg/dL can cause acute pancreatitis. Acute pancreatitis presents with severe epigastric pain and elevated serum amylase and lipase levels. Treatment is with intravenous fluids, pain control, and observation. Hypertriglyceridemia does not cause gallstones.

Answer 5: Infection of the bile ducts is the cause of ascending cholangitis. Patients with ascending cholangitis present with fever, abdominal pain, and jaundice, known as the Charcot triad. Additionally, severe disease presents with the additional findings of hypotension and altered mental status, known as the Reynolds pentad. Diagnosis is with an abdominal ultrasound or computed tomography scan and treatment is with antibiotics and biliary drainage.

Bullet Summary:
The most common gallstones are composed of cholesterol, which is caused by high cholesterol saturation in the bile.