Page created on September 11, 2021. Last updated on October 19, 2021 at 21:54
For introduction, epidemiology, etiology, pathomechanism, see the corresponding topic in pathology 2.
Uncomplicated (i.e., without cholecystitis, cholangitis, etc.) gallstone disease presents with biliary colic. This pain is intense, dull, constant, and is usually located in the right upper quadrant or epigastrium. The patient usually feels a strong urge to keep moving, rather than lying still. Worsening after food intake is typical but not always present. Sweating and nausea/vomiting is usually also present. Despite the name, the pain is usually constant rather than colicky. The attack usually lasts a few hours and rarely less than 30 minutes.
Cholecystitis usually presents with right upper quadrant pain which lasts longer than biliary colic, fever, nausea/vomiting, and positive Murphy sign (may be negative in elderly).
Cholangitis usually presents with Charcot’s triad of fever, abdominal pain, and jaundice.
Diagnosis and evaluation
Leukocytosis is often present in cholecystitis and cholangitis. An afebrile patient with biliary colic and normal WBCs likely has uncomplicated gallstone disease. Elevated liver enzymes, bilirubin, or jaundice is suspicious for choledocholithiasis, either cholangitis or pancreatitis.
Ultrasound is the most sensitive imaging modality for detecting gallbladder stones and is required for the diagnosis of gallstone disease. Ultrasound can also demonstrate gallbladder wall thickening or oedema, which gives the diagnosis of acute cholecystitis.
Abdominal CT may be used to rule out certain complicated gallstone diseases, like gangrenous cholecystitis, gallbladder perforation, emphysematous cholecystitis, or gallstone ileus.
- Gallstone ileus
- Acute gallstone pancreatitis
- Gallbladder gangrene or perforation
Gallstone ileus is a severe complication of gallstone disease where chronic inflammation of the gallbladder has formed a fistula between the gallbladder and duodenum, through which a gallstone can pass. This gallstone can obstruct the ileum, causing ileus. Gas inside the biliary tract on imaging is diagnostic.
Conservative treatment with antibiotics, nothing by mouth, and IV fluids is important. The definitive treatment for gallstone disease is antibiotic treatment and cholecystectomy. Cholecystectomy is almost always performed laparoscopically. There are two approaches to the timing of cholecystectomy, early surgery and delayed surgery.
In most cases, we opt for delayed surgery. In that case, the patient is treated conservatively, and if they respond to this the surgery is delayed for 6 – 8 weeks, after the acute inflammation has resolved. If the patient does not respond to initial conservative therapy, or they have indications for acute surgery like pericholecystic fluid or evidence of gangrene or perforation on imaging, surgery will be performed acutely.
People with only one episode of uncomplicated biliary colic often don’t undergo surgery unless they develop repeated episodes or complications later.
ERCP-guided biliary drainage and stone extraction is the treatment of choice for cholangitis.
Gallstone ileus requires emergency surgery. An enterotomy is made proximal to the stone, and the stone is then removed. Cholecystectomy and fistula closure should be performed at the same occasion or later.
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