Biliary tract diseases 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]

Cholelithiasis

Definitions

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.

Common Causes

Management

 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Asymptomatic
❑ Symptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic:
Gallstones identified during
❑ Imaging evaluation of abdominal and pelvic diseases
❑ Palpation of gallbladder at operation
 
 
 
 
 
Symptomatic:
❑ Abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic cholelithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Observation
❑ Expectant management
❑ Prophylactic cholecystectomy
 
❑ Biliary colic
❑ Right upper quadrant 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
 
 
 
 
 
❑ Abdominal pain not typical of biliary colic
❑ Right upper quadrant 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

❑ Diffuse abdominal pain
❑ Retrosternal heart burn
❑ Fluid regurgitation
❑ Belching
❑ Abdominal distension/bloating
❑ Early satiety/fullness after meals
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ No significant findings
 
 
 
 
 
Further evaluation for alternate diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
❑ CBC
❑ Serum total bilirubin
❑ AST
❑ ALT
❑ Serum alkaline phosphatase
❑ GGT
❑ Serum amylase
❑ Serum lipase
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order transabdominal USG (TAUSG)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:
❑ Biliary colic
❑ No significant abdominal findings during PE
❑ Normal CBC, LFT & pancreatic enzymes
❑ Gallstones/biliary sludge during TAUSG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptomatic & Uncomplicated cholelithiasis