Cholelithiasis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Overview

Terms Definitions
Cholelithiasis (gallstones) Cholelithiasis (gallstones) are crystallized pieces of bile including cholesterol and bilirubin in the gallbladder, which can range from microscopic to more than one inch in size and from one stone to hundreds in number.
Microlithiasis (biliary sludge) Microlithiasis (biliary sludge) are crystals and stones in the gallbladder that are too small to see with the naked eye.
Asymptomatic (incidential) cholelithiasis Asymptomatic (incidential) cholelithiasis refers to incidentally detected gallstones during routine ultrasound for other abdominal conditions or occasionally by palpation of the gallbladder at operation in patients who do not have any abdominal symptoms or have symptoms that are not thought to be due to gallstones.
Symptomatic and uncomplicated cholelithiasis Symptomatic and uncomplicated cholelithiasis refers to stones in the gallbladder that are associated with biliary colic in the absence of complications such as acute cholecystitis, cholangitis, or gallstone pancreatitis.
Symptomatic and complicated cholelithiasis Symptomatic and complicated cholelithiasis refers to stones in the gallbladder that are associated with upper abdominal pain, not typical of biliary colic in the presence of complications such as acute cholecystitis, cholangitis, or gallstone pancreatitis.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Cholelithiasis does not have any life-threatening causes.

Common Causes

Management

Shown below is a diagram depicting the management of cholelithiasis according to the Society for Surgery of the Alimentary Tract (SSAT)[2] and data from multiple studies.

 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Asymptomatic
❑ Symptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic:
Gallstones identified during
❑ Imaging evaluation of abdominal and pelvic diseases
❑ Palpation of gallbladder at operation
 
 
 
 
 
Symptomatic:
❑ Acute abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic cholelithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Observation
❑ Expectant management
❑ Prophylactic cholecystectomy
 
❑ Biliary colic
❑ RUQ or epigastric or substernal pain
❑ Sharp, intermittent and cramping pain
❑ Pain for at least 30 minutes (but <6 hours)
❑ Pain radiating to right shoulder blade
❑ Pain after food intake
❑ Pain not aggravated by movements
❑ Pain associated with nausea, vomiting and diaphoresis
❑ H/o recurrent attacks ranging from hours to years
 
 
❑ Acute abdominal pain not typical of biliary colic
❑ RUQ or epigastric or substernal pain
❑ Sharp, severe and steady pain
❑ Pain for >6 hours
❑ Pain radiating to right shoulder blade
❑ Pain after food intake
❑ Pain aggravated by movements
❑ Pain associated with nausea & vomiting
❑ Pain associated with diaphoresis
❑ Pain associated with fever
❑ Pain associated with anorexia
 
Atypical symptoms:
❑ Diffuse abdominal pain
❑ Retrosternal heart burn
❑ Fluid regurgitation
❑ Belching
❑ Abdominal distension/bloating
❑ Early satiety/fullness after meals
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ No significant findings
 
 
Examine the patient:
❑ Febrile
❑ Jaundice
❑ Tachycardia
❑ Tachypnea
❑ Hypotension
❑ Abdominal distension and/or tenderness
❑ Abdominal guarding
❑ Murphy's sign
❑ Altered mental status
 
Examine the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
❑ CBC
❑ BMP
❑ Total bilirubin
❑ Direct bilirubin
❑ Albumin
❑ AST
❑ ALT
❑ Alkaline phosphatase
❑ GGT
❑ Amylase
❑ Lipase
 
 
Symptomatic & complicated cholelithiasis:
Consider evaluation & management of
❑ Cholelithiasis associated complications
±
❑ Choledocholithiasis & choledocholithiasis associated complications
 
Consider evaluation for alternate diagnosis of abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order transabdominal USG (TAUSG)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:
❑ Biliary colic
❑ No significant findings during PE
❑ Normal CBC, LFT & pancreatic enzymes
❑ Gallstones/biliary sludge during TAUSG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Meets diagnostic criteria:
Symptomatic & Uncomplicated cholelithiasis
 
 
 
 
 
Does not meet diagnostic criteria:
❑ No gallstones/biliary sludge during TAUSG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute pain management:
❑ Ketorolac 30-60 mg IM/IV single dose
❑ Follow with 400 mg ibuprofen/opioids until cholecystectomy
 
 
 
 
w/ classical biliary colic
 
w/o classical biliary colic ± atypical symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Poor surgical candidates
 
Good surgical candidates
 
 
 
Repeat TAUSG in few weeks
 
Consider evaluation for alternate diagnosis of abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years/more[3]
 
Laparoscopic cholecystectomy
 
 
 
Gallstones/biliary sludge during TAUSG
 
No gallstones/biliary sludge during TAUSG
 
Diagnostic criteria:[4]
❑ Biliary colic
❑ Abnormal LFT
❑ Normal amylase/lipase
❑ GB visualized during TAUSG
❑ Sphincter of Oddi pressure >40 mmHg in sphincter of Oddi manometry
 
Suspect sphincter of Oddi dysfunction
 
❑ Nifedipine or nitrates
❑ ERCP with sphincterotomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cholecystokinin stimulated HIDA scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years
 
Microlithiasis
 
EUS w/ bile sampling[5]
 
GBEF >40%
 
Diagnostic criteria:[4]
❑ Biliary colic
❑ Normal LFT
❑ Normal amylase/lipase
❑ GB visualized during TAUSG
❑ GBEF <40%
 
Suspect functional gallbladder disorder
 
Cholecystectomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No microlithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider evaluation for alternate diagnosis of abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic metabolic profile; EUS: Endoscopic ultrasound; ERCP: Endoscopic retrograde cholangiopancreatography; GB: Gall bladder; GBEF: Gall bladder ejection fraction; GGT: Gamma-glutamyl transpeptidase; HIDA scan: Hepatobiliary iminodiacetic acid scan; H/O: History of; IM: Intramuscular; IV: Intravenous; LFT: Liver function test; PE: Physical examination; RUQ: Right upper quadrant; WBC: White blood cell; W/: With; W/:O With out

Do's

  • Repeat trans abdominal ultrasound in few weeks in patients suspected of cholelithiasis but neither gallstones or biliary sludge are detected during the initial ultrasound.
  • Do laparoscopic cholecystectomy in good surgical candidates as early as possible in order to avoid gallstone related complications.

Dont's

References

  1. Lammert, F.; Miquel, JF. (2008). "Gallstone disease: from genes to evidence-based therapy.". J Hepatol. 48 Suppl 1: S124–35. PMID 18308417. doi:10.1016/j.jhep.2008.01.012. 
  2. Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease.". J Gastrointest Surg. 16 (11): 2011–25. PMID 22986769. doi:10.1007/s11605-012-2024-1.  Unknown parameter |month= ignored (help)
  3. Tomida, S.; Abei, M.; Yamaguchi, T.; Matsuzaki, Y.; Shoda, J.; Tanaka, N.; Osuga, T. (1999). "Long-term ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute cholecystitis in patients with gallbladder stones: a cohort analysis.". Hepatology. 30 (1): 6–13. PMID 10385632. doi:10.1002/hep.510300108.  Unknown parameter |month= ignored (help)
  4. 4.0 4.1 Behar, J.; Corazziari, E.; Guelrud, M.; Hogan, W.; Sherman, S.; Toouli, J. (2006). "Functional gallbladder and sphincter of oddi disorders.". Gastroenterology. 130 (5): 1498–509. PMID 16678563. doi:10.1053/j.gastro.2005.11.063.  Unknown parameter |month= ignored (help)
  5. Liu, CL.; Lo, CM.; Chan, JK.; Poon, RT.; Fan, ST. (2000). "EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis.". Gastrointest Endosc. 51 (1): 28–32. PMID 10625791.  Unknown parameter |month= ignored (help)

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