B8. Clinical manifestations of gallstone disease. Laparoscopic cholecystectomy

Gallstone disease

Introduction

For introduction, epidemiology, etiology, pathomechanism, see the corresponding topic in pathology 2.

Clinical features

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.

Gallstone pancreatitis presents as any acute pancreatitis. Gallstone ileus is a rare form of complicated gallstone disease.

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.

Management

Pain control with NSAIDs or opioids are important. The definitive treatment for gallstone disease is antibiotic treatment and cholecystectomy, although not always performed in the acute setting. Cholecystectomy is almost always performed laparoscopically.

If the cholecystitis has lasted only a few days (2 – 4 days), laparoscopic cholecystectomy is usually performed in the acute setting. If the disease has lasted longer, surgery becomes more and more difficult due to gallbladder oedema, and the patient is usually treated conservatively with antibiotics in the acute setting and with an elective cholecystectomy approx. 6 weeks later, but this practice varies from place to place. Percutaneous gallbladder drainage is a possible adjunct to antibiotic treatment if the latter alone is insufficient.

People with only one episode of uncomplicated biliary colic often don’t undergo surgery unless they develop repeated episodes or complications later.

ERCP is the treatment of choice for cholangitis.


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B5. Acute appendicitis

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B12. Diverticulosis and diverticulitis

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