CHOLELITHIASIS

&
CHOLECYSTITIS

ERLINA MARFIANTI, MSC,SPPD

BLOK NUTRISI DAN DIGESTIVA, 25 APRIL 2011

OBJECTIVE
Understand and Identify the

anatomy of the biliary system

Describe the epidemiology of Biliary
diseases
Discuss the lab test and imaging
studies used to evaluate biliary
diseases
Compare and contrast biliary colic,
chronic cholecystitis, acute
(acalculous vs calculous)
cholecystitis, choledocholithiasis,
obstructive jaundice
Describe management of acute
Cholesistitis

ANATOMY
Calots Triangle: inferior margin of the liver

superiorly, CHD medially, cystic duct laterally

Gallbladder: Fundus, body, neck, cystic duct,
infundibulum
Sphincter of Oddi, Ampulla of Vater
Pancreatic ducts- Wirshung and Santorini

CHOLELITHIASIS (GALL STONE)

Spectrum of Gallstone Disease

Symptomatic

Cholelithiasis

cholelithiasis can
be a herald to:
an attack of acute
cholecystitis
or ongoing chronic
cholecystitis
May also resolve

Asymptomatic Symptomatic
cholelithiasis cholelithiasis

Chronic
calculous
cholecystitis

Acute
calculous
cholecystitis

Epidemiology
Although 10% to 15% of people in the United States

develop gallstones,
fewer than half of those with gallstones have
symptoms, and fewer than 10% develop potentially
life-threatening complications
Cholesterol gallstones are less common in black
people

Risk Factor
4 Fs: FEMALE, FAT, FERTILE, FORTY
Other risk factors: Estrogen preparat use, rapid

weight loss, family history, chronic hemolysis, SB

resection, Total Parental Nutrition , Crohns disease
(terminal ileum)
DM, Insulin Resistance,
Drugs: Clofibrate, octreotide, ceftriaxon
Prolonged fasting microlithiasis

Gallstones
Uncommon in children (seen with hemolytic,

idiopathic, cystic fibrosis, obesity, ileal resection,

long term use of TPN)
Elderly
14-27% symptomatic gallstone disease
More likely biliary sepsis/gangrenous GB
perioperative morbidity
Mortality rate 19%

Gallstone Risk Factors

Familial
Asian descent
Chronic biliary tract infections
Parasitic infections (ascaris lumbricoides)
Chronic liver disease
Chronic intravasular disease (Sickle Cell,

Hereditary Scherocytosis)
Hepatitis A, B, C, E
HIV
Herpesvirus

Bile is made up of what?

Cholesterol, bile acids, phospholipids (lecithin),

conjugated bilirubin, protein

Predominantly chemical compisition gallstone:
cholesterol or calcium bilirubinate stones
Gallbladder sluge assoc prolonged TPN, starvation,
rapid weight loss.

Precursor to gallstones

Clinically Presentation
Bilary colic = cystic duct blockage from impacted

stones
History/PE

Postprandial abdominal pain RUQ radiating to scapula,

epigastric pain

The pain may last from several minutes to several hours.

Abrupt onset, and gradual relief, nausea, vomiting.
Usually fatty food intolerance, dyspepsia, flatulence

Jaundice

Biliary Colic
The pain of biliary colic is from contraction of the

gallbladder, which cannot empty because the cystic

duct is obstructed by a stone.
The gallbladder is stimulated to contract primarily
by cholecystokinin, which is released from the small
bowel mucosa.
The pain resolves after the gallbladder stops
contracting or when the cystic duct becomes patent
again.

Cinically Presentation
Acute cholecystitis
is the initial presentation of symptomatic gallstones in

15% to 20% of patients.

Patients with acute cholecystitis experience severe pain
that persists for several hours, until they finally seek help
at a local emergency room.
Whereas in biliary colic the cystic duct obstruction is
transient, in acute cholecystitis it is persistent.
Persistent cystic duct obstruction, in combination with
chemical irritants in the bile, results in inflammation and
edema of the gallbladder wall.
Nausea and vomiting are common.

Clinically Examination
mild epigastric or right upper quadrant tenderness,
but most patients do not have significant physical

findings.
Acute Cholecystitis
marked tenderness in the right upper quadrant, often
associated with a definite mass or fullness.
Palpation of the right upper quadrant during inspiration
often causes such severe discomfort that the patient stops
inspiring (a positive Murphy sign).
Local peritoneal signs
and fever are common.

Diagnosis
Diagnosis:
Abdominal

ultrasound: gallstones (85-90%)

scan: r/o cystic duct obstruction, CBD obstruction
Cholescintigraphy 95% accurate in the outpatient diagnosis
of acute cholecystitis
LFTs:

ALT, AST, ALK PHOS, TB, DB

Amylase, Lipase
CBC

 About 10% of stones are radiopaque

Can be viewed with radiographic contrast
Sonography is now the method of choice
Composition of stones vary
cholesterol, bilirubin, calcium

Gallstones

http://www.goldbamboo.com/pictures-t1349.html

Treatment
Treatment:
eletive cholecystectomy
Extracorporeal shock wave lithotripsy (ESWL)
or oral solution Ursodeoxycholic acid (only for
cholesterol stones)
Complications of cholelithiasis: recurrent biliary
colic pain, choledocholithiasis, pancreatitis,
cholangitis

How to decrease the risk of gallstone formation?

Avoid obesity
High fiber diet
Low saturated fat diets
Small meals at regular intervals

Choledocholithiasis
Can present similarly to cholelithiasis, except with

the addition of jaundice

DDx: cholelithiasis, hepatitis, sclerosing cholangitis,
less likely CA with pain
Tx: Endoscopic retrograde
cholangiopancreatography (ERCP)

Stone extraction and sphincterotomy

Interval cholecystectomy after recovery from ERCP

Biliary Tract Emergencies Related to Gallstones

1) Biliary Colic
2) Cholecystitis
3) Gallstone pancreatitis
4) Ascending cholangitis

Cholecystitis
Pathophysiology

Inflammation of the
Gallbladder
Cholelithiasis
Chronic Cholecystitis

Bacterial infection

Acalculus Cholecystitis

Burns, sepsis, diabetes

Multiple organ failure

Cholecystitis
Signs & Symptoms

URQ Abdominal Pain

Murphys sign

Steady, severe pain, and tenderness

Nausea, Vomiting
Fever and leucocytosis
Jaundive Mirrizys syndrome
History of Cholecystitis

Risk Factors for Acute Cholecystitis

Associated with gall stone
Critical ill patients
Caused By Infectious agents

Pathogens Involved in Acute

Cholecystitis
E. coli/Klebsiella-70%
Enterococci-15%
Bacteroides-10%
Clostridium-10%
Group D Strep
Staphylococcal species

Clinical Features
Overlap of UD, gastritis, GERD, nonspecific

dyspepsia
RUQ pain
Upper abd/epigastric pain
Radiation to L upper back
Pain persisant lasting 2-6h

Differential Diagnosis
Gastritis

Appendicitis (pregnancy,

GERD

retrocecal)
PID
Fitzhugh-Curtis Syn.
Ectopic
Pneumonia
Pleural Effusion

Pancreatis
Hepatitis
PUD
AMI in elderly
Acute renal colic
Acute pyelo

Clinical Features of Acute Cholecystitis

Pain
Nausea,Vomitus
Anorexia
Fever, chills
+Murphys sign ( pain or

inspiratory arrest with deep,

subcostal palpation on
inspiration

Acute calculous cholecystitis

Persistent cystic duct

obstruction leads to Gall B

ladder distension, wall
inflammation & edema
Can lead to: empyema,
gangrene, rupture
Pain usu. persists >24hrs &
Nausea &Vomitus&Fever
Palpable/tender or even
visible RUQ mass
Nuclear HIDA scan shows
nonfilling of GB

Acalculous Cholecystitis
5-10% incidence

GB torsion

Elderly

Systemic vasculitis states

DM

Bacterial or parasitic

Multiple trauma
Extensive burns
Prolonged Labor
Major surgery

infection of biliary tract

Acute acalculous cholecystitis

In 5-10% of cases of acute cholecystitis
Seen in critically ill or prolonged TPN
More likely to progress to gangrene, empyema,

perforation due to ischemia

Caused by gallbladder stasis from lack of enteral
stimulation by cholecystokinin
Tx: NPO, IVF, Antibiotika
Cholecystectomy
Treat of underlying disease

Complications of acute cholecystitis

Empyema of
gallbladder

Pus-filled GB(Gall Bladder) due to bacterial

proliferation in obstructed GB. Usu. more
toxic, high fever

Emphysematous More commonly in men and diabetics. Severe

cholecystitis
RUQ pain, generalized sepsis. Imaging

shows air in GB wall or lumen

Perforated
gallbladder

Occurs in 10% of acute cholesistitis, usually

becomes a contained abscess in RUQ
Less commonly, perforates into adjacent
viscus = cholecystoenteric fistula & the stone
can cause SBO (gallstone ileus)

Chronic calculous cholecystitis

Recurrent inflammatory process due to recurrent

cystic duct obstruction, 90% of the time due to

gallstones
Overtime, leads to scarring/wall thickening

Diagnostic Studies
Most important is high clinical suspicion

and U/S.
Usually labs (CBC, bilirubin, Alk. Phos, LFTs,
Lipase)
CXR12 Lead EKG- r/o ACS
USG
CT when ? other intraabdominal path
HIDA Scan

Complications
Fluid & Electrolyte deficiencies- due to vomiting &

anorexia
Upper GI hemorrhage- Mallory-Weiss tears
Gallstone pancreatitis
Ascending cholangitis
Cholecystitis
GB Empyema
Emphysematous (gangrenous) GB

Treatment
Uncomplicated Symptomatic Cholelithiasis No

immediate surgery, Elective cholecystectomy,

Control symptoms
Antispasmodics
Opiates (Meperidine preferred)
Antiemetics
Ketorolac (relieves GB distention)
Replace fluids & electrolytes

Tx: NPO, IVF,

Antibiotika
Cholecystectomy

Treatment
Acute Acalculous/Calculous Cholecystitis
If septic wide spectrum abx and immediate surgery
If not septic single agent abx (3rdgen

cephalosporin), surgery within 24-72 hours

Cholangitis
Infection of the bile ducts due to CBD obstruction

2ndary to stones, strictures

Charcots triad
May lead to life-threatening sepsis and septic
shock
Tx: NPO, IVF, IV Abx
Emergent decompression via ERCP or perc
transhepatic cholangiogram (PTC)
Used to require emergency laparotomy

All of the following are risk factors for

development of gallstones except:
A. Pregnancy
B. >50 yoa
C. Female
D. Obesity
E. Asian descent

4) Clinical features of cholecystitis include all of

the following except:

A. RUQ abdominal pain
B. Radiation to R upper back
C. Nausea, Vomiting
D. + Murphys sign
E. Fever