• Clinical science

Cholelithiasis, choledocholithiasis, cholecystitis, and cholangitis

Summary

Cholelithiasis refers to the presence of abnormal concretions (gallstones) in the gallbladder and choledocholithiasis refers to gallstones in the common bile duct. About 10–20% of American adults have gallstones. Gallstones most commonly consist of cholesterol but may be pigmented (due to hemolysis or infection) or mixed. Both cholelithiasis and choledocholithiasis can manifest with postprandial RUQ pain, nausea, and vomiting. The diagnosis is confirmed by ultrasound, although choledocholithiasis may also require ERCP. Symptomatic cholelithiasis is managed with laparoscopic cholecystectomy. Choledocholithiasis requires stone removal, usually via ERCP.

Cholecystitis is inflammation of the gallbladder that most commonly occurs after cystic duct obstruction from cholelithiasis (calculous cholecystitis). Acalculous cholecystitis is less common and seen primarily in critically ill patients. In addition to the Murphy sign (inspiratory arrest during RUQ palpation due to pain), typical signs include fever and RUQ guarding. The diagnosis is made clinically and confirmed via ultrasound. Cholescintigraphy (HIDA scan) is a useful adjunctive diagnostic tool if ultrasound is unrevealing. The definitive treatment for complicated cholecystitis is laparoscopic cholecystectomy, either performed within 72 hours of onset or after a course of antibiotics when inflammation subsides (usually after at least 6 weeks). Complications of cholecystitis include gallbladder gangrene and rupture, empyema, gallstone ileus, emphysematous cholecystitis, and abscess formation. Chronic gallbladder inflammation also increases the risk of gallbladder carcinoma.

Cholangitis (also known as ascending cholangitis or acute cholangitis) is an infection of the biliary tract. It is caused by obstruction of the biliary tree, which may lead to bile stasis and subsequent bacterial infection. Clinically it is characterized by the Charcot triad, which consists of abdominal pain, fever, and jaundice, although jaundice is not always present. Sepsis and septic shock may develop as a complication of acute cholangitis. The diagnosis should be suspected in patients with fever, elevated inflammatory markers, and jaundice or abnormal liver enzymes. Treatment includes resuscitation, broad-spectrum antibiotics, and urgent biliary drainage.

Overview

Cholelithiasis Choledocholithiasis Acute cholecystitis Acute cholangitis
Mechanism
Clinical features
Laboratory findings
  • Normal
Diagnostic imaging
  • US: gallstones with posterior acoustic shadow
  • US: dilated common bile duct, intrahepatic biliary dilatation
  • MRCP or ERCP: filling defect in the contrast-enhanced duct
  • US: biliary dilation and/or evidence of obstruction (e.g., cholelithiasis)
  • MRCP if diagnosis uncertain
Treatment

Cholelithiasis

Epidemiology [1][2]

  • Sex: > (2–3:1)
  • Prevalence: approx. 10–20% of the adult population in the US
  • Peak incidence: : > 40 years

Etiology

Cholesterol stones; ∼ 80% of all stones [1][2]

During pregnancy, increased estrogen levels cause increased secretion of lithogenic bile (rich in cholesterol), resulting in the formation of cholesterol gallstones. Increased progesterone levels cause smooth muscle relaxation, decreased and impaired gallbladder contraction, and subsequent bile stasis and formation of gallstones.

Rule of the 6 Fs: Fat, Female, Fertile, Forty, Fair-skinned, Family history.

Black pigment stones, ∼ 10% of all stones [3][1][4]

Mixed (brown pigment stones); ∼ 10% of all stones [3][1][4][5]

Clinical features [6][7]

  • Most gallstones are asymptomatic.
  • Biliary colic: constant, dull RUQ pain lasting < 6 hours
    • Especially postprandial
    • May radiate to the epigastrium, right shoulder, and back (referred pain)
  • Nausea, vomiting, early satiety
  • Bloating, dyspepsia

Only a minority of patients with gallstones are symptomatic!

Diagnostics [6]

  • Approach: conduct RUQ ultrasound → perform further imaging (EUS or MRCP) if concurrent common bile duct stones are suspected or if US is equivocal
  • Laboratory findings: usually normal in uncomplicated cholelithiasis
  • Imaging:
    • RUQ ultrasound: best initial test (85–90% sensitivity, 99% specificity) [8]
      • Shows gallstones with posterior acoustic shadow, possible sludge
    • Endoscopic ultrasound (EUS) is more sensitive than transabdominal ultrasound.
    • MRCP only if concurrent common bile duct stones are suspected

X-ray is rarely diagnostic because only 10–15% of stones (i.e., pigment stones) are radiopaque. Cholesterol stones are radiolucent!

Laboratory test results (e.g., WBC count, bilirubin, amylase) are usually normal in uncomplicated cholelithiasis!

Treatment [9][10][11][12][13]

Cholecystectomy is usually not indicated in asymptomatic cholelithiasis!

Complications [15][16]

Choledocholithiasis

Epidemiology [17][5]

Etiology [7][1]

Clinical features [17][7]

Diagnostics [17]

Treatment [17][19][14]

Complications [20]

Cholecystitis

Acute calculous cholecystitis (90–95%)

Epidemiology [21]

Etiology [21]

Clinical features [21][22][23][12][7]

Acute cholecystitis should always be suspected in a patient with a history of gallstones who presents with RUQ pain, fever, and leukocytosis.

Diagnostics [21][22][23]

Treatment [24][14][25]

Subtypes and variants

Acalculous cholecystitis (5–10%) [27]

Emphysematous cholecystitis (rare) [21][22][23]

Complications of acute cholecystitis [24]

Complications of chronic cholecystitis

Chronic gallbladder inflammation increases the risk of gallbladder carcinoma!

Complications of laparoscopic cholecystectomy [16]

Cholangitis

Epidemiology [28]

Etiology [28][29]

Clinical features [28][29]

Diagnostics [28]

  • Approach: conduct laboratory tests → imaging modality depends on clinical features present
  • Laboratory findings
  • Imaging
    • ERCP (both diagnostic and therapeutic)
    • Ultrasound: biliary dilation, evidence of obstruction (e.g., cholelithiasis)
    • CT scan; MRCP may also be diagnostic

Treatment [29][26][28]

Complications

Differential diagnoses

References:[23][30]

The differential diagnoses listed here are not exhaustive.