Cholelithiasis


Article Author:
Jasmin Tanaja


Article Editor:
Jehangir Meer


Editors In Chief:
Susan Johnson
Alexandra Caley


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
1/27/2019 8:39:14 AM

Introduction

Cholelithiasis or gallstones are hardened deposits of digestive fluid that can form in your gallbladder. The gallbladder is a small organ located just beneath the liver. The gallbladder holds a digestive fluid known as bile that is released into your small intestine. In the United States, 6% of men and 9% of women have gallstones, most of which are asymptomatic. In patients with asymptomatic gallstones discovered incidentally, the likelihood of developing symptoms or complications is 1% to 2% per year. Asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree do not need treatment unless they develop symptoms. However, approximately 20% of these asymptomatic gallstones will develop symptoms over 15 years of follow-up. These gallstones may go on further to develop complications such as cholecystitis, cholangitis, choledocholithiasis, gallstone pancreatitis, and rarely cholangiocarcinoma.[1][2][3]

Etiology

There are three main pathways in the formation of gallstones: 

  • Cholesterol supersaturation: Normally, bile can dissolve the amount of cholesterol excreted by the liver. But if the liver produces more cholesterol than bile can dissolve, the excess cholesterol may precipitate as crystals. Crystals are trapped in gallbladder mucus, producing gallbladder sludge. With time, the crystals may grow to form stones and occlude the ducts which ultimately produce the gallstone disease.
  • Excess bilirubin: Bilirubin, a yellow pigment derived from the breakdown of red blood cells, is secreted into bile by liver cells. Certain hematologic conditions cause the liver to make too much bilirubin through the processing of breakdown of hemoglobin. This excess bilirubin may also cause gallstone formation.
  • Gallbladder hypomotility or impaired contractility: If the gallbladder does not empty effectively, bile may become concentrated and form gallstones.

Depending on the etiology, gallstones have different compositions. The three most common types are cholesterol gallstones, black pigment gallstones, and brown pigment gallstones. Ninety percent of gallstones are cholesterol gallstones.

Each stone has a unique set of risk factors. Some risk factors for the development of cholesterol gallstones are obesity, age, female gender, pregnancy, genetics, total parenteral nutrition, rapid weight loss, and certain medications.

Approximately 2% of all gallstones are black and brown pigment stones. These can be found in individuals with high hemoglobin turnover. The pigment consists of mostly bilirubin. Patients with cirrhosis, ileal diseases, sickle cell anemia, and cystic fibrosis are at risk of developing black pigment stones. Brown pigments are mainly found in Southeast Asian population and are not common in the United States. Risk factors for brown pigment stones are intraductal stasis and chronic colonization of bile with bacteria.[4][5][6][7]

Epidemiology

Cholelithiasis is quite common and can be found in approximately 6% of men and 9% of women. The highest prevalence of cholelithiasis arises in Native American populations. Gallstones are not as common in Africa or Asia. The epidemic of obesity has likely magnified the rise of gallstones.

Despite how prevalent gallstones may be, more than 80% of people remain asymptomatic. Biliary pain, however, will develop annually in 1% to 2% of individuals previously asymptomatic. Those who started to develop symptoms may continue to have major complications (cholecystitis, choledocholithiasis, gallstone pancreatitis, cholangitis) occur at a rate of 0.1% to 0.3% yearly.

Pathophysiology

Cholesterol gallstones are formed mainly due to over secretion of cholesterol by liver cells and hypomotility or impaired emptying of the gallbladder. In pigmented gallstones, conditions with high heme turnover, bilirubin may be present in bile at higher than normal concentrations. Bilirubin may then crystallize and eventually form stones.

Symptoms and complications of cholelithiasis result when stones obstruct the cystic duct, bile ducts or both. Temporary obstruction of the cystic duct (as when a stone lodges in cystic duct before the duct dilates and the stone returns to gallbladder) results in biliary pain but is usually short-lived. This is known as cholelithiasis. More persistent obstruction of cystic duct (as when a large stone gets permanently lodged in the neck of the gallbladder) can lead to acute cholecystitis. Sometimes a gallstone may get pass through the cystic duct and get lodged and impacted the common bile duct, and causes obstruction and jaundice. This complication is known as choledocholithiasis.

If gallstones pass through the cystic duct, common bile duct and get dislodged at the ampulla of the distal portion of the bile duct, acute gallstone pancreatitis may result from backing up of fluid and increase pressure in pancreatic ducts and in situ activation of pancreatic enzymes. Occasionally, large gallstones do perforate the gallbladder wall and create a fistula between the gallbladder and small or large bowel, producing bowel obstruction or ileus.

History and Physical

Patients with gallstone disease typically present with symptoms of biliary colic (intermittent episodes of constant, sharp, right upper quadrant (RUQ) abdominal pain often associated with nausea and vomiting), normal physical examination findings, and normal laboratory test results. It may be accompanied by diaphoresis, nausea, and vomiting.

  • Biliary colic is usually caused by the gallbladder contracting in response to some form of stimulation, forcing a stone through the gallbladder into the cystic duct opening, leading to increased gallbladder wall tension and pressure which often result in pain known as biliary colic. As the gallbladder relaxes, the stones often fall back into the gallbladder, and the pain subsides within 30 to 90 minutes.
  • Fatty meals are a common trigger for gallbladder contraction. The pain usually starts within an hour after a fatty meal and is often described as intense and dull, and may last from 1 to 5 hours. However, an association with meals is not universal, and in a significant proportion of patients, the pain is nocturnal. The frequency of recurrent episodes is variable, though most patients do not have symptoms on a daily basis.
  • A thorough physical exam is useful to distinguish biliary pain due to acute cholecystitis, uncomplicated cholelithiasis or other complications.  
  • In an uncomplicated biliary colic, the patient is afebrile and has an essentially benign abdominal examination without rebound or guarding.

Acute cholecystitis occurs when persistent stone dislodged the cystic duct causes the gallbladder to become distended and inflamed. The patient may also present with fever, pain in the right upper quadrant and tenderness over the gallbladder (this is known as Murphy's sign).

When fever, persistent tachycardia, hypotension, or jaundice are present, it requires a search for complications of cholelithiasis, including cholecystitis, cholangitis, pancreatitis, or other systemic causes.

Choledocholithiasis is a complication of gallstones when stones obstruct the common bile duct it impedes the flow of bile from the liver to the intestine. Pressure rises resulting in elevation of liver enzymes and jaundice.

Cholangitis is triggered by colonization of bacteria and overgrowth in static bile above an obstructing common duct stone. This produces purulent inflammation of the liver and biliary tree. Charcot's triad consists of severe RUQ tenderness with fever and jaundice and is classic for cholangitis. Surgical removal of stone obstruction with intravenous antibiotics is required to treat this condition.

Evaluation

Initial labs to evaluate gallstones often include CBC, CMP, PT/PTT, lipase, amylase, Alk Phos, total bilirubin, urine analysis.

Ultrasound remains the first line and best imaging modality to diagnose gallstones. A systematic review estimated that the sensitivity was 84% and specificity was 99%, better than other modalities. Either radiology ultrasound study or point-of-care ultrasound can be used to detect biliary disease. Several studies in the literature have shown that point-of-care ultrasound by clinicians is accurate and reliable in diagnosing or excluding biliary disease. Gallstones on ultrasound have the appearance of hyperechoic structures within the gallbladder with distal acoustic shadowing. Sludge in gallbladder may also be seen, with an appearance of hyperechoic layering within the gallbladder. Sludge, unlike stones, does not cast acoustic shadowing.  If the following additional signs are noted, suspicion should be raised for acute cholecystitis:  thickened anterior gallbladder wall (greater than 3 mm), the presence of pericholecystic fluid or positive sonographic Murphy's sign. Additionally, common bile duct (CBD) measurements can be obtained by ultrasound, and if increased, can suggest choledocholithiasis. The normal range of CBD is four mm in patients up to 40 years of age, with additional 1 mm allowed for every additional decade of life.  Post-Cholecystectomy patients are allowed up to 10 mm diameter since the common duct become the bile reservoir once the gallbladder is removed.

If an ultrasound study is equivocal for ruling out acute cholecystitis, then a nuclear medicine cholescintigraphy scan, also known as a HIDA scan can be performed. In a normal healthy gallbladder, a radioactive tracer injected into a peripheral vein is circulated to the liver where it enters the biliary tree and gets taken up into the gallbladder within 4 hours. A diseased gallbladder with cystic duct obstruction will prevent the tracer from entering the gallbladder. HIDA scan has a sensitivity of up to 97% and specificity of 94% for the diagnosis of acute cholecystitis.

CT imaging of the abdomen does not add to increased sensitivity or specificity for diagnosing gallstones or cholecystitis. It can be helpful in determining if CBD dilatation is present, and can detect pancreatic inflammation or complications (masses, pseudo-cysts, necrotizing features). CT imaging is also useful if RUQ ultrasound excludes biliary disease and other causes of abdominal pain are being sought.

Additionally, tests such as endoscopic or magnetic retrograde cholangiopancreatography (ERCP/MRCP) are sometimes useful when working up patients with jaundice and dilated CBD or suspected cholangitis, but are usually obtained after an ultrasound. ERCP is an invasive test, requiring the use of contrast dye but also has the advantage of allowing intervention if pathology is found (e.g., stenting, stone extraction, biopsy).  MRCP, on the other hand, is non-invasive and does not require contrast dye.

Treatment / Management

Management of gallstones can be divided into two categories: asymptomatic gallstones and symptomatic gallstones. Asymptomatic gallstones require patient to be counseled re symptoms of biliary colic and when to seek medical attention. Cholelithiasis without complications can be treated acutely with oral or parenteral analgesia in emergency department or urgent care center once the diagnosis has been established and alternative diagnoses excluded. Patients should also be offered dietary advice to reduce the chance of recurrent episodes and referred to a general surgeon for elective laparoscopic cholecystectomy. Patients with symptoms and workup consistent with acute cholecystitis will require admission to hospital, surgical consult and intravenous antibiotics.  Patients with choledocholithiasis or gallstone pancreatitis will also require admission to hospital, gastrointestinal (GI) consultation and ERCP or MRCP. Patients with acute ascending cholangitis are usually ill-appearing and septic. They often also require aggressive resuscitation and ICU-level care in addition to surgical intervention to drain an infection in the biliary tract.[8][9][10]

Pearls and Other Issues

Cholelithiasis is on a spectrum of biliary disease that ranges from asymptomatic patients to patients with frequent episodes of biliary colic. Complications related to gallstones may develop, such as choledocholithiasis and cholecystitis. Definitive treatment for symptomatic stones is cholecystectomy. Ultrasound is the primary modality for diagnosing gallstones. Point-of-care ultrasound has been shown in the hands of trained operators to be as accurate as radiology ultrasound in the detection of gallstones.

Enhancing Healthcare Team Outcomes

The diagnosis and management of gallstones is multidisciplinary. The majority of patients present to the emergency department with right upper quadrant pain and the work up reveals gallstones. The management of gallstones depends on patient symptoms. Asymptomatic patients should be educated on a low-fat diet, exercise and weight loss. There is little evidence to support surgery for patients with asymptomatic gallstones. For those who are symptomatic, referral to a general surgeon is recommended. Today, the standard of care is laparoscopic cholecystectomy which is performed as an outpatient. Some patients with gallstones may develop bile duct stones or cholangitis and need admission. The prognosis for most patients managed conservatively or with surgery is excellent.[11] (Level II)

 


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Cholelithiasis - Questions

Take a quiz of the questions on this article.

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Which statement about the oral cholecystogram is FALSE?



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A woman with gallstones wants to have them removed non-surgically. Which of the following is false about non-surgical treatments to treat gallstones?



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Which of the following is used to treat gallstones?



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A female presents with right upper quadrant pain, nausea, vomiting, and diaphoresis. The pain is dull and radiates to her back. She is unable to catch her breath. What will a bedside ultrasound most likely show?



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What percentage of patients have stones in the common duct at gallbladder surgery?



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Plain radiographs are of little diagnostic value with gallstones. What percentage of gallstones are radiopaque on plain radiographs?



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Which of the following is incorrect about ultrasound?



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Which of the following is not normally found in the chemical makeup of a gallstone?



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Which is not a risk factor for gallstones?



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Which of the following is NOT a classic risk factor for gallstones?



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In a patient with gallstones, what is the mechanism of action of ursodeoxycholic?



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Which of the following is NOT caused by gallstones?



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Which is not a major risk factor for cholesterol gallstones?



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Which of the following statements about gallstones is not true?



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Which of the following statements regarding cholecystectomy is false?



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Which oral medication can be used to treat gallstones?



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Which of the following statements about pigmented gallstones is not true?



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Which of the following is the least likely finding on ultrasound in a patient with cholelithiasis?



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Which of the following is NOT one of the three types of gallstones?



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What factor determines the timing for cholecystectomy for biliary colic during pregnancy?



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What is the most likely cause of episodic jaundice in a 33-year-old female?



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Which of the following is FALSE about CT in the evaluation of a patient with bile duct obstruction?



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Which is FALSE about MRCP?



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Which of the following is NOT a risk factor for gallstones?



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Gallstones found in patients with sickle cell anemia are composed primarily of which of the following compounds?



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A 43-year-old G3P3, obese female presents with chronic flatulence and upper abdominal pain 1 to 2 hours after eating a fatty meal. Which of the following hormones is responsible for her symptoms?



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A 44-year-old female presents complaining of a three-week history of intermittent postprandial epigastric pain and is found to have multiple gallstones on abdominal ultrasound. Which of the following treatment plans is appropriate?



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Gallstones that have eroded through the posterior wall of the gallbladder enter which part of the gastronintestinal tract?



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What is the initial imaging test of choice in a 40-year-old woman with right upper quadrant pain after meals, normal physical exam, and comprehensive metabolic panel?



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A 40-year-old obese G4P4004 presents with right upper quadrant pain starting 90 minutes after a meal of fried chicken and French fries. Acute cholecystitis is the working diagnosis. Which of the following statements is true?



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A 45 year old woman develops severe right upper quadrant abdominal pain. Cholelithiasis is suspected. What finding on urine dipstick would be most suggestive of this diagnosis?



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Which of the following conditions does not increase the risk of cholelithiasis?



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What is considered the primary imaging modality for detection of cholelithiasis?



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What is the wall-echo-shadow sign (also known as WES sign) on ultrasound?

Attributed To: Contributed by Emory Emergency Medicine Ultrasound section



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Plain x-rays are of little diagnostic value with gallstones. What is the percentage of radio-opaque gallstones visualized on a plain x-ray?



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A forty-year-old female patient presents to the emergency department due to severe right upper quadrant abdominal pain. It started earlier this afternoon after having a cheeseburger and fries for lunch. You suspect a problem with her biliary system. After a pregnancy test comes back negative, what imaging test would you order to evaluate for biliary pathology?



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Cholelithiasis - References

References

Kurzweil A,Martin J, Transabdominal Ultrasound 2018 Jan;     [PubMed]
Di Ciaula A,Portincasa P, Recent advances in understanding and managing cholesterol gallstones. F1000Research. 2018;     [PubMed]
Chen X,Yan XR,Zhang LP, Ursodeoxycholic acid after common bile duct stones removal for prevention of recurrence: A systematic review and meta-analysis of randomized controlled trials. Medicine. 2018 Nov;     [PubMed]
Chung AY,Duke MC, Acute Biliary Disease. The Surgical clinics of North America. 2018 Oct;     [PubMed]
Yoo KS, [Management of Gallstone]. The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi. 2018 May 25;     [PubMed]
Rebholz C,Krawczyk M,Lammert F, Genetics of gallstone disease. European journal of clinical investigation. 2018 Jul;     [PubMed]
Ibrahim M,Sarvepalli S,Morris-Stiff G,Rizk M,Bhatt A,Walsh RM,Hayat U,Garber A,Vargo J,Burke CA, Gallstones: Watch and wait, or intervene? Cleveland Clinic journal of medicine. 2018 Apr;     [PubMed]
Yeh DD,Chang Y,Tabrizi MB,Yu L,Cropano C,Fagenholz P,King DR,Kaafarani HMA,de Moya M,Velmahos G, Derivation and validation of a practical Bedside Score for the diagnosis of cholecystitis. The American journal of emergency medicine. 2019 Jan;     [PubMed]
Kruger AJ,Modi RM,Hinton A,Conwell DL,Krishna SG, Physicians infrequently miss choledocholithiasis prior to cholecystectomy in the United States. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. 2018 Feb;     [PubMed]
Parkin E,Stott M,Brockbank J,Galloway S,Welch I,Macdonald A, Patient-Reported Outcomes for Acute Gallstone Pathology. World journal of surgery. 2017 May;     [PubMed]
Akhtar-Danesh GG,Doumouras AG,Bos C,Flageole H,Hong D, Factors Associated With Outcomes and Costs After Pediatric Laparoscopic Cholecystectomy. JAMA surgery. 2018 Jun 1;     [PubMed]

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