1.8.1 Cholelithiasis and Cholecystitis

Question 1

Describe risk factors for gall stones

Answer 1

• Female gender
• Older age
• Obesity / metabolic syndrome
• Northern European or Native American ancestry
• Pregnancy
  
  • Progesterone decreases gallbladder motility
• Rapid weight loss
  
  • Diet, gastric bypass
• Medications
  
  • Fibrates (to treat dyslipidemia)
  • Estrogen (OCP)
  • Somatostatin analogues (octreotide)
• Low bile salt resorption
  
  • Chron’s dz, surgery to ileum
• High heme turnover
  
  • Sickle cell anemia
  • Beta-thalassemia
  • Hemolysis
  • Cirrhosis / portal hypertension

Question 2

Describe the four stages of gallstone dz

Answer 2

• Lithogenic State
  
  • Allows for stone development
• Asymptomatic gallstones
  
  • May last for decades
• Symptomatic gallstones
  
  • Biliary colic episodes
  • Stones block cystic duct
  • Spasm
• Complicated cholelithiasis

Question 3

Describe biliary colic

Answer 3

• Poorly localized pain
• Typically, 30m then plateaus at 60m
• Resolved < 6h
• If pain lasts > 6h, may indicate acute cholecystitis
• Benign abd exam
  
  • No rebound or guarding
• Afebrile!

Question 4

Describe acute calculus cholecystitis

Answer 4

• Acute cholecystitis
  
  • Gallbladder inflammation
• Acute calculus cholecystitis
  
  • Caused by gallstones
  • Most common type of cholecystitis
  • Usually seen in people with previous sx related to gallstones, i.e. biliar colic
  • Can become gangrenous

Question 5

Describe acute acalculous cholecystitis

Answer 5

• Gallstones typically not present
  
  • 5-10% of cases
• Risk factors: r/t decreased gallbladder activity
  
  • TPN
  • Critical illness, sepsis
  • Prolonged fasting

Question 6

Describe physical findings of your acute cholecystitis patient

Answer 6

• RUQ/Epigastric Pain
  
  • Constant, severe
  • Radiate to right shoulder (Colins sign)
  • Radiate to back
  • Rebound/guarding common
  • • Murphy sign
      
      • Tenderness upon palpation in RUQ
  • Pain 1-2h after eating fatty food
  • N/V common
• Low grade fever
  
  • May not have fever
• Tachycardia
• Dehydration
• Hypoactive bowel sounds
  
  • May have normal BS

Question 7

Your patient presents with RUQ quandrant pain that starts about 1h after eating and lasts about 6h. What labs will you want to order to rule out acute cholecystitis?

Answer 7

• CBC
  
  • Inflammatory markers, infxn?
  • Leukocytosis?
    
    • Bandemia common in acute chole (left shift)
• CMP
  
  • Look at lytes, BUN, Scr, s/o dehydration
• LFTs
  
  • Elevated bilirubin?
    
    • May indicate choledolcolithiasis
    • Esp if jaundice and/or scleral icterus are present
• Lipase
  
  • Concomitant pancreatitis?

Question 8

You suspect biliary or gallbladder dz… what is the preferred imaging exam?

What terminology might you see on report from radiology?

Answer 8

RUQ ultrasound

• Terminology
  
  • Hydrops or hydropic gallbladder
    
    • Typically d/t stone lodged in cystic duct for protracted period
    • Bile unable to enter gallblader
    • Bilirubin absorption normally occurs in gallbladder
    • Distended gallbladder filled with colorless, mucoid fluid
  • Porcelain gallbladder
    
    • Calcified gallbladder results from stones
    • Increased risk for gallbladder cancer
    • Presence is indication for surgery

Question 9

You’re working up your patient for cholecystitis. Describe cholescintigraphy?

What is a Rim Sign?

Describe false positive HIDA results?

How do you prep your patient for HIDA scan?

Answer 9

• Hepatic 2,6-dimethylliminodiacetic acid (HIDA) scan
  
  • Highly Se and Sp for acute cholecystitis compared to chronic cholecystitis
• Normal HIDA scan: gallbladder visible in 30m of tracer injected
• Cholecystitis:
  
  • Inability to visualize gallbladder in 60m d/t cystic duct obstruction (no bile going into gallbladder)
  • Inability to visualize small intestine occurs with CBD obstruction
• Rim Sign
  
  • Increased peri-cholecystic radiotracer activity seen next to gallbladder
    
    • 30% of patients with acute cholecystitis
    • 60% of patients with acute gangrenous cholecystitis
• False positive: 10-20% incidence, likelier if:
  
  • Hyperbilirubinemia over 4.4 mg/dL
  • Recent food intake
  • Fasting > 24h
  • TPN
  • Severe hepatic dz
  • Chronic biliary duct inflammation
  • History of biliary sphincterotomy
• False negative: 15% at 30-60m
• Preparation for HIDA Scan:
  
  • NPO 4-6h prior to scan
  • If CCK admin planned: No opioids for 6h (or 4 half-lives) - opioids interfere with gallbladder contractility
  • Meds to hold:
    
    • CCBs
    • H2 blockers
    • BZDs
    • Octreotide
    • Progesterone
    • Indomethacin
    • Theophylline

Question 10

You are HIDA-scanning your patient, but not bc you are concerned for acute cholecystitis. What’s the other related issue you might be investigating?

What’s the role of CCK-stimulation?

Answer 10

• Biliary dyskinesia / functional gallbladder dz
  
  • Preferred terms for ‘chronic’ cholecystitis
  • Abd pain caused by chronic gallbladder inflammation
  • A/w frequent acute episodes of cholecystitis thought to cause gallbladder fibrosis and thickening
    
    • Stones commonly involved
    • Sphincter of Oddi may be involved
• CCK-Stimulated CHolescintigraphy
  
  • Cholecystokinin infusion used to dx functional gallbladder dz
    
    • Incidence 2.5-5% of adults
    • Biliary colic pain 1-2h post-meals, but more common at night
    • No evidence of cholelithiasis or structural causes on RUQ ultrasound
  • Positive: Gallbladder ejection fraction < 40%

Question 11

What are the possible complications of acute cholecystitis?

Answer 11

• Gangrenous cholecystitis
  
  • Most common complication (20%)
  • Risk factors: older age, DM, delay in seeking care
  • May present septic
• Gallbladder perforation
  
  • Occurs in roughly 10% of acute cholecystitis cases
  • Risk factors: delay in seeking tx
• Emphysematous cholecystitis
  
  • Gallbladder wall develops secondary infection with gas producing organisms
    
    • Clostridium welchii
    • Clostridia = gas forming organisms
  • May or may not have palpable subQ emphysema (crepitus) in abd wall in area of gallbladder
• Cholecystoenteric fistula
  
  • Gallstone fistulizes through gallbladder into small bowel (usually duodenum)
    
    • D/t long-standing pressure necrosis
  • Can lead to diarrhea d/t bile acids
• Gallstone ileus
  
  • Can occur if stone > 2.5cm passes through cholecystoenteric fistula
  • Can cause mechanical bowel obstruction in terminal ileum