Gallstones (Cholelithiasis)

Normal gallbladder vs Gallbladder with stone

Acute cholecystitis

• Cholelithiasis is a condition in which stones accumulates in gallbladder
• Choledocholithiasis is a condition in which stone is in the common bile duct
• Factors that can cause gallstones are Increase in the amount of circulating cholesterol and bilirubin, decrease in bile salts and motility of gall bladder.
• 2 common type of gallstones are cholesterol stones (most common) and pigment stones

Gallstones can cause: 

• Cholecystitis (ReelDx video # 2) 
• Ascending cholangitis
• Acute pancreatitis
• Gallstone ileus

Symptoms:

• Can be asymptomatic
• Intense pain in the upper-right side of the abdomen that often worsens after a meal
• Nausea and vomiting

Risk factors

• Obesity
• Female gender and oral contraceptive use (high estrogen promotes gallstone formation)
• Pregnancy
• Crohns disease, cystic fibrosis, drugs, chronic hemolysis, alcoholic cirrhosis, advanced age, biliary infections

Diagnosis

• Physical exam (Murphy sign is present in cholecystitis, however, USG must be done to confirm any diagnose related to gallstones)
• Ultrasonography (best initial test), Abdominal X-ray is the most common wrong answer on USMLE.
• Abdominal CT scan (if no stones found on USG)
• MRCP
• Blood workup (CMP, amylase, lipase, Beta-HCG, urine analysis and CBC)

Management

• Depends on the diagnosis and presentation

For asymptomatic gallstones

• Ursodeoxycholic acid for 6-18 months (dissolves cholesterol gallstones), but high recurrence once a drug is stopped.
• Close follow-up of diabetics and pregnant
• Do cholecystectomy if stone > 2 cm 

For symptomatic gallstones

• Nasogastric suction, NPO, IV fluids, Antibiotics (first step of management in acute cholecystitis) followed by cholecystectomy later on.
• Do emergent cholecystectomy in case of perforation (generalized peritonitis)
• Routine ERCP before laparoscopic cholecystectomy is not indicated, however, It is indicated in the treatment of choledocholithiasis, that is identified during cholecystectomy with intraoperative cholangiography.
• Endoscopic sphincterotomy (if surgery is not possible and stone is in bile duct)

Extra high yield note: 

• In few cases like ICU patient, gallbladder may become inflamed in the absence of a gallstone, known as acalculous cholecystitis
• Murphy sign is positive in cholecystitis, but negative in choledocholithiasis, pyelonephritis, and ascending cholangitis

Related ReelDx Cases: 

---

Article by- Dr. Chirag Navadia, Founder of MedRx Education and Author of Fundamentals of Cardiology, 2015
ReelDx videos- Keith Cross, MD, University of Louisville,
Chris Moore, MD, Yale School of Medicine and David Spiro, MD, Oregon Health & Science University

---