• Clinical science

Cholelithiasis and cholecystitis

Abstract

Cholelithiasis refers to the presence of abnormal concretions (gallstones) in the gallbladder. About 10–20% of American adults have gallstones. Predisposing factors include female gender, increasing age (> 40 years), obesity, family history, and hemolytic disorders. Gallstones most commonly consist of cholesterol but may be pigmented (due to hemolysis or infection) or mixed. Cholelithiasis may be an incidental finding or present with typical symptoms of postprandial right upper quadrant (RUQ) pain, nausea, and vomiting. Diagnosis is confirmed by ultrasound. Asymptomatic cholelithiasis does not warrant treatment. Symptomatic disease is managed by laparoscopic cholecystectomy. Cholecystitis, choledocholithiasis, and gallstone pancreatitis are the most common complications of cholelithiasis.

Cholecystitis is defined as inflammation of the gallbladder that occurs most commonly after cystic duct obstruction by cholelithiasis (calculous cholecystitis). Acalculous cholecystitis is less common and seen in critically ill patients. Murphy's sign (inspiratory arrest during RUQ palpation due to pain), fever, and RUQ guarding are typical signs. Diagnosis is made clinically and confirmed with ultrasonography. Cholescintigraphy (HIDA scan) is a useful adjunct in certain equivocal cases. 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 at least 6 weeks). Complications of cholecystitis include gallbladder gangrene and rupture, empyema, gallstone ileus, emphysematous cholecystitis, and abscess formation.

Definition

Epidemiology

Cholelithiasis

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

Choledocholithiasis

Cholecystitis

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Cholelithiasis

  • Imbalance of bile salts, lecithin (stabilizer), diluted substances (cholesterol, calcium carbonate, bilirubin) and gallbladder stasis
  • Risk factors

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

Choledocholithiasis

Cholecystitis

References:[2][4][5][1]

Classification

Cholecystitis

Pathophysiology

Cholelithiasis

Choledocholithiasis

Cholecystitis

References:[6][7]

Clinical features

Cholelithiasis

  • Only 25% of patients with gallstones have symptoms!
  • Biliary colic (colicky RUQ pain)
    • Especially postprandial
    • May radiate to the epigastrium, right shoulder, and back
  • Nausea, vomiting, feelings of satiety
  • Bloating, dyspepsia

Choledocholithiasis

Cholecystitis

  • RUQ pain
    • More severe and prolonged (> 6 hours) than in cholelithiasis
    • Worse after meals
    • Radiation to the right scapula
    • Guarding
    • Positive Murphy's sign describes sudden inspiratory arrest during RUQ palpation. The sitting version was described by John Murphy (hence the name, Murphy's sign).
  • Fever, malaise
  • Nausea and vomiting

References:[8][1][9][10][2]

Subtypes and variants

Acalculous cholecystitis

  • Definition: : acute necroinflammatory disorder of the gallbladder, usually seen in critically ill patients. It usually presents with secondary infection.
  • Etiology: conditions that result in biliary stasis (e.g., multiorgan failure, severe trauma, surgery, sepsis, total parenteral nutrition, prolonged fasting) and a "stressed gallbladder" with reduced perfusion
  • Clinical features: fever, RUQ tenderness
  • Diagnostics
    • Ultrasound demonstrates thickening of the gallbladder wall without presence of gallstones or sludge
    • Blood cultures
  • Treatment
    • Initial treatment: antibiotics
    • Cholecystostomy is often preferred because it is less invasive, especially considering most patients are critically ill.
    • If patient does not improve after cholecystostomy, a cholecystectomy is required.

Emphysematous cholecystitis

  • Definition: : rare form of acute cholecystitis that occurs more often in elderly diabetic males
  • Etiology: infection of gallbladder with gas-forming bacteria (e.g., Clostridium welchii)
  • Clinical features: fever, RUQ pain, absent peritoneal signs with possible crepitus in abdominal wall (rare), associated with early gangrene and gallbladder perforation
  • Diagnostics: ultrasound or CT demonstrates air in the gallbladder wall or lumen.
  • Treatment: emergency cholecystectomy

References:[1][9]

Diagnostics

Cholelithiasis

  • Best initial test: ultrasonography
    • Shows gallstones with posterior acoustic shadow, possible sludge This may also occur after long-standing bowel rest (especially with parenteral nutrition) without the potential of lithogenesis. Sludge appears on ultrasound as a hyperechoic sediment on the floor of the gallbladder, with a distinct fluid-level. If the entire gallbladder is filled with sludge it may appear entirely hyperechoic (echogenic bladder), making the distinction between gallbladder lumen and adjacent organs (e.g., liver) very difficult. Sludge does not produce an acoustic shadow by definition and must be differentiated from thicker and more echogenic sediment (e.g., lithiasis), leading to an acoustic shadow.
  • Endoscopic ultrasound (EUS) of the bile ducts to exclude choledocholithiasis
  • Gastroscopy: exclude other etiologies of abdominal pain

Choledocholithiasis

  • Approach: conduct laboratory tests and transabdominal ultrasound to determine risk of choledocholithiasis → further confirmatory imaging if necessary (i.e., intermediate or low risk)
  • Laboratory tests
  • Imaging
    • Transabdominal ultrasonography
      • Dilated common bile duct with possible intrahepatic biliary dilatation
      • Depending on the location, the occluding stone may be visualized
    • Confirmatory diagnosis
      • If high risk of choledocholithiasisERCP (see “Treatment” below)
      • If intermediate risk →; magnetic resonance cholangiopancreatography (MRCP; ) or EUS
      • If low risk → treatment if evidence of cholelithiasis (no further imaging)

Cholecystitis

  • Ultrasonography
    • Enlargement of the gallbladder
    • Wall thickening > 4 mm (postprandial > 5 mm)
    • Double wall sign
    • Possible free fluid surrounding the gallbladder
    • Sonographic Murphy's sign
    • Presence of concrement or gallstones in 90% of cases
    • Gaseous collections
  • 99mTc-hepatic iminodiacetic acid (HIDA) scan (cholescintigraphy)
    • Perform if US is not diagnostic
    • Procedure: radioactive tracer IV HIDA is injected → selective uptake by hepatocytes → subsequent excretion into bile → can be visualized via a gamma camera
    • Abnormal if gallbladder not visualized within 30–60 minutes: suggests cystic duct obstruction due to edema or obstructing stone
  • Laboratory tests

References:[8][1][9]

Differential diagnoses

References:[9][11]

The differential diagnoses listed here are not exhaustive.

Treatment

Cholelithiasis

  • Conservative
    • Fasting or dietary modification (decreased fat intake)
    • Spasmolytics (e.g., dicyclomine)
    • Analgesia: NSAIDs
  • Interventional
    • Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy
      • A procedure that displays bile and pancreatic ducts by introducing a gastroduodenal endoscope and injecting contrast through the ampulla of Vater
      • Papillotomy (sphincterotomy) widens the ampulla of Vater to facilitate better passage of bile and pancreatic secretions (as well as gallstones)
      • Indications: symptomatic cholelithiasis, choledocholithiasis, acute cholangitis, gallstone pancreatitis
      • Following ultrasound, commonly the next best step of management for gallstones: both diagnostic and therapeutic (papillotomy, stone extraction using DORMIA basket) purposes
      • Complication rate of up to 10%
        • Post-ERCP pancreatitis (5% of cases): postinterventional pain over 24 hours with simultaneous rise in pancreatic enzymes (lipase, amylase)
        • Hemorrhaging (3% of cases)
        • Cholangitis (3% of cases)
        • Perforation (1% of cases)
      • Should generally still conduct interval cholecystectomy (to avoid recurrence)
    • Medical litholysis
    • Extracorporeal shock wave lithotripsy (ESWL, cholelithotripsy): stone destruction
      • Possible in up to 3 noncalcified gallstones, with a maximal diameter of 3 cm
      • Retained contraction capacity must be present (to remove stone debris)
      • Additional medical litholysis is necessary
      • Success rate: > 90% of patients, success less common with increased size of stone (e.g., > 2 cm)
      • Contraindications: pregnancy, infection, coagulopathy
  • Surgical
    • Indication: symptomatic patient with proven lithiasis
    • Procedure: elective laparoscopic cholecystectomy (after ERCP)
      • Relative contraindication: blood coagulation disorder, Mirrizzi syndrome, intraperitoneal adhesions from previous surgery
      • Absolute contraindication: gallbladder carcinoma
      • Implementation
        • Supine position of the patient during general anesthesia
        • Introduction of four entry points
        • Elevation of the liver and identify the gallbladder
        • Preparation of the Calot triangle (cystohepatic triangle)
        • Clip (ligate) the cystic duct and the cystic artery
        • Separation of the clipped structures
        • Detachment of the gallbladder
        • Wash, hemostasis and extraction of the gallbladder, possibly (especially with inflammatory process) with insertion of a drain
        • Withdrawal and closure, layer by layer, including the skin
        • Sterile dressing
      • Conventional cholecystectomy
        • Open, using a right costal arch incision

Only symptomatic patients should have surgery!

Choledocholithiasis

  • Interventional: if there is biliary obstruction, the stone must be removed
    • ERCP with papillotomy (both diagnostic and therapeutic)
    • Elective cholecystectomy (after ERCP)

Cholecystitis

References:[1][12][10][13][2][14][15]

Complications

Complications of cholelithiasis

Chronic gallbladder inflammation increases the risk of gallbladder carcinoma!

Complications of cholecystectomy

  • Injury to bile ducts or the hepatic artery (especially with accidental incorrect clipping)
  • Gallbladder fistulae
  • Hemorrhage
  • Subhepatic abscess
  • Postcholecystectomy syndrome
    • Description: persistent abdominal pain or new symptoms following gallbladder removal
    • Frequency: 10–15% of patients
    • Etiology: : both biliary (e.g, biliary injury, retained cystic duct, sphincter of Oddi dysfunction) and extrabiliary causes (e.g., irritable bowel syndrome, pancreatitis) have been identified
    • Clinical features: abdominal pain and upper GI tract (e.g., dyspepsia) or lower GI tract (e.g., diarrhea) symptoms
    • Diagnosis: ultrasound or CT scan followed by ERCP (preferred test if intervention is planned) or MRCP
    • Treatment: depends on the identified cause, but may involve endoscopic sphincterotomy (e.g., in patients with sphincter of Oddi dysfunction) or transduodenal sphincteroplasty

References:[16][17][18][19][20]

We list the most important complications. The selection is not exhaustive.