Surgical and Nonsurgical Management of Gallstones

Question 1

What is the medical term for gallstones?

Answer 1

Cholelithiasis

Question 2

Which groups of people are at risk for cholelithiasis?

Answer 2

people with diabetes mellitus, persons who are obese, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives, specific races (Chilean Indians, Mexican Americans). Incidence increases with age

Question 3

T or F. Most patients are asymptomatic; gallstones are discovered incidentally during ultrasonography or other imaging of the abdomen.

Answer 3

T

Question 4

What is the rate for asymptomatic patients have to develop symptoms?

Answer 4

about 2% per year. Only 10% to 20% of asymptomatic patients will eventually become symptomatic within five to 20 years of diagnosis

Question 5

Once symptoms appear, the usual presentation of uncomplicated gallstones is _______.

Answer 5

biliary colic, caused by the intermittent obstruction of the cystic duct by a stone

Question 6

Describe the pain of biliary colic?

Answer 6

The pain is characteristically steady, is usually moderate to severe in intensity, is located in the epigastrium or right upper quadrant of the abdomen, lasts one to five hours, not relieved with bowel movement, and gradually subsides as the stone dislodges

Question 7

What is the best way to spot gallstones?

Answer 7

Ultrasonography (highly sensitive for detection of gallstones). Computed tomography should be considered in patients with negative or equivocal ultrasonography results or if com- plications of gallstones are suspected

Question 8

Complications of biliary colic include?

Answer 8

Acute cholecystitis, gallstone pancreatitis, and ascending cholangitis

Question 9

What are gallstones?

Answer 9

solid calculi formed by precipitation of supersaturated bile composed of cholesterol monohydrate crystals or by ‘‘black pigment’’ of polymerized calcium bilirubinate.

Question 10

What is the major component of most gallstones?

Answer 10

cholesterol

Question 11

Gallstones are associated with which diseases?

Answer 11

Gallstones are associated with high-calorie diets, type 2 diabetes mellitus, dyslipidemia, hyper-insulinism, obesity, and metabolic syndrome

Question 12

Patients with biliary colic usually present with pain where?

Answer 12

acute onset of pain in the right upper quadrant of the abdomen or epigastrium (dermatomes T8/9) caused by brief impaction of the gallstone in the neck of the gallbladder CAUSED by brief impaction of the gallstone in the neck of the gallbladder

Question 13

T or F. More than 90% of patients presenting with a first episode of biliary colic have recurrent pain within 10 years (two- thirds of those within two years)

Answer 13

T

Question 14

What is Acute cholecystitis?

Answer 14

complication of gallstones. inflammation of the gallbladder caused by gallstones blocking the cystic duct

Question 15

Acute cholecystitis should be suspected in patients that present with what symptoms?

Answer 15

fever, leukocytosis, right upper quadrant mass, persistent pain, a mild elevation of bilirubin levels, or Murphy sign (inspiratory arrest during deep right upper quadrant palpation)

It generally follows food intake and often occurs in patients with prior attacks of biliary colic

Question 16

What is Choledocholithiasis?

Answer 16

Complication of gallstones. gallstones that have migrated from the gallbladder into the common bile duct, most often via the cystic duct

Choledocholithiasis is found in 6% to 12% of patients with gallstones; it increases the risk of recurrent symptoms, gallstone pancreatitis, and cholangitis (Ascending cholangitis is character- ized by fever, jaundice, and abdominal pain (Charcot triad))

Question 17

What is gallstone pancreatitis?

Answer 17

obstruction at the level of the sphincter of Oddi, typically pres- ent with epigastric pain and increased amylase and lipase levels.

Question 18

What scanning approach can be used to diagnosis acute cholecystitis?

Answer 18

hepatobiliary iminodiacetic acid (HIDA)

Question 19

What is the best approach for patients with incidentally detected, asymptomatic gallstones?

Answer 19

expectant management

Question 20

Exceptions to expectant management incude?

Answer 20

patients with calcification of the gallbladder, hemolytic anemia, or large gallstones (greater than 3 cm); patients with small gallstones and gallbladder dysmotility; patients who are morbidly obese and undergoing bariatric surgery; patients planning to have a transplant; and Native Americans

Question 21

T or F. Prophylactic treatment, usually with laparoscopic cholecystectomy, should be recommended for patients with biliary-type symptoms or those with complications of gallstones, because these patients are likely to have recurrent and more severe symptoms

Answer 21

T

Question 22

What should the testing approach for patients with gallstones on imaging but atypical symptoms by?

Answer 22

other common gastrointestinal diagnoses should be considered, such as peptic ulcer disease, gastroesophageal reflux disease, or irritable bowel syndrome

Question 23

What should the testing approach for patients presenting with symptoms highly suggestive of gallstones but without gallstones on imaging?

Answer 23

a cholecystokinin-HIDA scan should be considered

In up to 20% of the patients with symptoms typical of biliary colic, no gallstones are seen on imaging, possibly because of small size or stone composition

Question 24

Treatment of acute biliary colic primarily involves pain control with ______.

Answer 24

NSAIDs

Question 25

Should all symptomatic gallstones be removed via surgery (i.e. is it always necessary?)?

Answer 25

No, expectant management is also a valid alternative. For example, in one study of 69 adults with symptomatic gallstones treated expectantly, only 35 required chole- cystectomy after a median follow-up of 5.6 years.

Question 26

Which is the preferred surgical route for complicated gallstones, laparoscopic cholecystectomy or open cholecystectomy?

Answer 26

laparoscopic surgery was similar to the open procedure in complication rates and surgical time, but resulted in a shorter hospital stay

Question 27

What are some dissolution agents used to treatment gallstones?

Answer 27

Actigall. Decreases hepatic secretion of biliary cholesterol, cause formation of unsaturated bile, and promote dissolution of cholesterol crystals and gallstones. After six to 12 months of therapy, it may eventu- ally result in dissolution of small gallstones, but with a recurrence rate of more than 50%

Question 28

What are the main disadvantages of oral dissolution?

Answer 28

lengthy time frame of observation (up to two years). Fewer than 10% of patients with symptomatic gallstones are candidates for this therapy

NOTE: For asymptomatic pigmented or calcified gallstones, no medical therapy aside from pain control is recommended. Oral dissolution is used for cholesterol containing gallstones

Question 29

Treatment of gallstones in pregnant women

Answer 29

In pregnant women with symptomatic gallstones, the initial management is supportive care, which is usually successful.46 Because NSAIDs are generally not recom- mended in pregnancy, pain control can be achieved with intravenous administration of meperidine. Ursodeoxy- cholic acid has been administered in pregnant patients to manage intrahepatic cholestasis, but the safety and effectiveness of treating gallstones during pregnancy have not been evaluated (U.S. Food and Drug Admin- istration pregnancy category B). Chenodeoxycholic acid should not be used in pregnant patients (U.S. Food and Drug Administration pregnancy category X). Surgery is usually reserved for patients with recurrent or intracta- ble biliary pain or those who have complications related to gallstones. When surgery is indicated, the laparo- scopic approach is preferred, and has been used safely in all trimesters

Question 30

Treatment of gallstones in elderly or critically ill patients

Answer 30

The clinical presentation of gallstones in older patients may be different because of impaired cognition and the presence of comorbidities. A history of biliary colic might be difficult to obtain, and in patients with acute cholecystitis, fever and Murphy sign are often absent. Although surgery is the treatment of choice for acute cholecystitis, it is associated with increased mortality in older persons.
In patients who are critically ill with gallbladder empyema and sepsis, cholecystectomy can be life threatening. In this circumstance, the surgeon may elect to perform percutaneous cholecystostomy, which involves placement of a percutaneous-transhepatic-cholecystostomy tube using computed tomography or ultrasonography guidance, with delayed interval cholecystectomy. Once the patient’s condition is more stable, definitive chole- cystectomy can be performed

Question 31

Treatment of gallstones in patients with cirrhosis.

Answer 31

Because of gallbladder dysfunction and increased hemo- lysis, patients with cirrhosis have a higher rate of gall- stones than the general population. These patients also present significant surgical challenges with risk of liver failure and significant bleeding in the face of portal hypertension. Laparoscopic cholecystectomy is the pro- cedure of choice for those with Child-Pugh class A and B cirrhosis