Gallstone disease physical examination: Difference between revisions

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__NOTOC__
__NOTOC__
{{Gallstone disease}}
{{Gallstone disease}}
{{CMG}}
==Overview==


Gallstones usually remain asymptomatic initially.<ref>{{cite web |url=http://www.emedicine.com/med/topic836.htm#section~clinical |title=Cholelithiasis |accessdate=2007-08-25 |work=emedicine from WebMD}}</ref> They start developing symptoms once the stones reach a certain size (>8mm).<ref>{{cite web |url=http://www.nlm.nih.gov/medlineplus/ency/article/000273.htm#Symptoms%20Medline%20Plus |title=Gallstones |accessdate=2007-08-25 |work=Medline Plus}}</ref> A main symptom of gallstones is commonly referred to as a gallstone "attack", also known as '''biliary colic''', in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately thirty minutes to several hours. A victim may also encounter pain in the back, ordinarily between the shoulder blades, or pain under the right shoulder. In some cases, the pain develops in the lower region of the abdomen, nearer to the pelvis, but this is less common.
{{CMG}}; {{AE}} {{HM}}
====Biliary colic====
'''Biliary colic''' is [[pain]] associated with irritation of the viscera secondary to [[cholecystitis]] and gallstones.  Unlike renal colic, the phrase 'biliary colic' refers to the actual [[cholelithiasis]].


Though unlike renal colic, the phrase 'biliary colic' refers to the actual cholelithiasis.  Although it is frequently described as
==Overview==
a [[colic]], the pain is steady, starts rapidly and lasts at least 30 minutes and up to several hours. Many patients complain of right upper quadrant pain, rt flank pain, or even mid chest pain with cholelithiasis. There may be  
Patients with gallstones are usually not ill-appearing and don't have [[fever]] or [[tachycardia]]. Physical examination of patients with gallstones is sometimes remarkable for [[Abdominal pain|right upper quadrant pain]], [[epigastric]] tenderness, [[Abdominal guarding|guarding]] and [[jaundice]]. Symptoms occurs when stones reach more than 8 mm in size. [[Courvoisier's sign]] (a [[palpable]] [[gallbladder]] on physical examination) may be [[Palpate|palpated]] when the [[common bile duct]] becomes obstructed and the [[gallbladder]] becomes dilated. This mostly occurs with [[malignant]] [[common bile duct]] obstruction, but has been reported with gallstone disease.
irradiation to the back and shoulders and other concomitant symptoms such as [[vomiting]] and [[diarrhea]]. Fatty foods
==Physical Examination==
can provoke biliary pain, but this association is relatively non-specific.


Biliary pain can be associated with objective findings (dilation of the biliary tract, elevation of plasma liver enzyme
*Gallstones are usually [[asymptomatic]].
concentration, elevation of bilirubin, gamma-GT and alkaline phosphatase).
*This means that gallstones are discovered incidentally when [[imaging studies]] are obtained for another reason.  
=====Causes=====
*Physical findings become relevant when a stone blocks the [[common bile duct]], this could lead to the development of [[biliary colic]] up to [[Jaundice|obstructive jaundice]].  
Biliary pain is most frequently caused by obstruction of the [[common bile duct]] or the [[cystic duct]] by a [[gallstone]]. However,
*The pain is usually referred to the back, ordinarily between the shoulder blades, or there is pain under the right shoulder (Collins' sign). Eventually, the [[pain]] subsides.<ref name="pmid18000708">{{cite journal |vauthors=Yang MH, Chen TH, Wang SE, Tsai YF, Su CH, Wu CW, Lui WY, Shyr YM |title=Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy |journal=Surg Endosc |volume=22 |issue=7 |pages=1620–4 |year=2008 |pmid=18000708 |doi=10.1007/s00464-007-9665-2 |url=}}</ref><ref name="pmid19190960">{{cite journal |vauthors=Fitzgerald JE, White MJ, Lobo DN |title=Courvoisier's gallbladder: law or sign? |journal=World J Surg |volume=33 |issue=4 |pages=886–91 |year=2009 |pmid=19190960 |doi=10.1007/s00268-008-9908-y |url=}}</ref>
the presence of [[gallstones]] is a frequent incidental finding and does not always necessitate treatment,  
in the absence of identifiable disease. Furthermore, biliary pain may be associated with functional disorders of the
biliary tract, so called acalculous biliary pain, and can even be found in patients post-cholecystectomy (removal
of the gallbladder), possibly as a consequence of dysfunction of the [[biliary tree]] and the sphincter of oddi.
=====Differential Diagnosis=====
*Amoebic liver abscess
*Perforated peptic ulcer
*Upper small bowel obstruction.
=====Complications=====
The more serious complication is total blockage of the bile duct which leads to [[jaundice]], which if it is not corrected naturally or by a surgical procedure can be fatal as it causes [[liver]] damage.


The presence of gallstones can lead to infection of the gall bladder (cholecystitis) or the biliary tree
[[Image:jaundice.jpg|thumb|center|200px|Source: Wikipedia. Patient with jaundice<ref name="urlJaundice - Wikipedia">{{cite web |url=https://en.wikipedia.org/wiki/Jaundice#/media/File:Jaundice08.jpg |title=Jaundice - Wikipedia |format= |work= |accessdate=}}</ref>]]
(cholangitis) or acute inflammation of the pancreas (pancreatitis). Rarely, an impacted gallstone can obstruct
the bowel, causing [[gallstone ileus]] (mechanical [[ileus]]).


Biliary pain in the absence of gallstones may severely impact the patient's quality of life, even in the absence
===Appearance of the Patient===
of disease progression.
*Patients with gallstones usually appear to be well.
=====Presentation=====
*Patients with [[obstructive jaundice]] may exhibit a yellowish discoloration of the [[skin]] and [[sclera]] of the eyes.
This condition causes crescendos of severe pain in the [[right upper abdomen]] and sometimes through to the upper [[back]] and/or right shoulder.  The pain relates to the obstruction of the passage of bile and can be associated with eating fatty foods. There is usually an inflammatory component to the pain as the characteristic colic is not completely relieved between crescendos.
[[Image:jaundice1.jpg|thumb|center|500px|Source: Wikipedia. Patient with scleral icterus<ref name="urlJaundice - Wikipedia">{{cite web |url=https://en.wikipedia.org/wiki/Jaundice#/media/File:Jaundice08.jpg |title=Jaundice - Wikipedia |format= |work= |accessdate=}}</ref>]]


Often, these attacks occur after a particularly fatty meal and almost always happen at night.
===Vital Signs===
=====Treatment=====
*[[Fever]]
These attacks are intensely painful, similar to that of a [[kidney stone]] attack. One way to alleviate the abdominal pain is to drink a full glass of water at the start of an attack to regulate the bile in the [[gallbladder]], but this does not work in all cases. Another way is to take magnesium followed by a bitter liquid such as [[coffee]] or [[swedish bitters]] an hour later. Bitter flavors stimulate bile flow. A study has found lower rates of gallstones in coffee drinkers.<ref>{{cite web |url=http://jama.ama-assn.org/cgi/content/abstract/281/22/2106t |title=A Prospective Study of Coffee Consumption and the Risk of Symptomatic Gallstone Disease in Men |accessdate=2007-08-25 |work=The Journal of the American Medical Association}}</ref>
*[[Tachycardia]] with regular pulse


Pain management is an important part of treating biliary colic.  Treatment is often with [[NSAIDs]] such as [[ketorolac]] (Toradol) and [[diclofenac]] (Voltaren).  [[Hyoscine butylbromide]] (Buscopan) is occasionally used but is less effective than analgesics.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=882 |title=BestBets: Buscopan (hyoscine butylbromide) in biliary colic. |format= |work= |accessdate=}}</ref>
===Skin===
*[[Jaundice]]


====Other symptoms====
===Abdomen===
Other symptoms include
*[[Abdominal distention]]  
*[[Jaundice]]
*[[Abdominal tenderness]] in the right upper abdominal quadrant
*[[Nausea]] and [[vomiting]]
*[[Rebound tenderness]] (positive [[Blumberg sign]])
*[[Diarrhea]]
*A palpable [[abdominal mass]] in the right upper abdominal quadrant (positive [[Courvoisier's sign]])
*[[Bleeding]] caused by continuous vomiting
*[[Guarding]] may be present
*[[Dehydration]] caused by the nausea and diarrhea.
*Abdominal bloating
*Intolerance of fatty foods
*Belching
*Indigestion.
If the above symptoms coincide with chills, [[low-grade fever|lowgrade fever]], yellowing of the skin or eyes, and/or clay-colored stool, a doctor should be consulted immediately.<ref name="nih_gall">{{cite web |url=http://digestive.niddk.nih.gov/ddiseases/pubs/gallstones/index.htm#symptoms |title=Gallstones |accessdate=2007-08-25 |work=National Digestive Diseases Information Clearinghouse}}</ref>


Some people who have gallstones are asymptomatic and do not feel any pain or discomfort. These gallstones are called "silent stones" and do not affect the [[gallbladder]] or other internal organs. They do not need treatment.<ref name="nih_gall"/>
===HEENT===
*[[Jaundice|Icteric sclera]]


==References==
==References==
{{reflist|2}}
{{Reflist|2}}


{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Gastroenterology]]
[[Category:Hepatology]]
[[Category:Surgery]]
[[Category:Disease]]

Latest revision as of 21:48, 29 July 2020

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

Overview

Patients with gallstones are usually not ill-appearing and don't have fever or tachycardia. Physical examination of patients with gallstones is sometimes remarkable for right upper quadrant pain, epigastric tenderness, guarding and jaundice. Symptoms occurs when stones reach more than 8 mm in size. Courvoisier's sign (a palpable gallbladder on physical examination) may be palpated when the common bile duct becomes obstructed and the gallbladder becomes dilated. This mostly occurs with malignant common bile duct obstruction, but has been reported with gallstone disease.

Physical Examination

  • Gallstones are usually asymptomatic.
  • This means that gallstones are discovered incidentally when imaging studies are obtained for another reason.
  • Physical findings become relevant when a stone blocks the common bile duct, this could lead to the development of biliary colic up to obstructive jaundice.
  • The pain is usually referred to the back, ordinarily between the shoulder blades, or there is pain under the right shoulder (Collins' sign). Eventually, the pain subsides.[1][2]
Source: Wikipedia. Patient with jaundice[3]

Appearance of the Patient

  • Patients with gallstones usually appear to be well.
  • Patients with obstructive jaundice may exhibit a yellowish discoloration of the skin and sclera of the eyes.
Source: Wikipedia. Patient with scleral icterus[3]

Vital Signs

Skin

Abdomen

HEENT

References

  1. ↑ Yang MH, Chen TH, Wang SE, Tsai YF, Su CH, Wu CW, Lui WY, Shyr YM (2008). "Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy". Surg Endosc. 22 (7): 1620–4. doi:10.1007/s00464-007-9665-2. PMID 18000708.
  2. ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
  3. ↑ 3.0 3.1 "Jaundice - Wikipedia".

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