Cholelithiasis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Overview

Terms	Definitions
Cholelithiasis (gallstones)	Cholelithiasis (gallstones) are crystallized pieces of bile including cholesterol and bilirubin in the gallbladder, which can range from microscopic to more than one inch in size and from one stone to hundreds in number.
Microlithiasis (biliary sludge)	Microlithiasis (biliary sludge) are crystals and stones in the gallbladder that are too small to see with the naked eye.
Asymptomatic (incidential) cholelithiasis	Asymptomatic (incidential) cholelithiasis refers to incidentally detected gallstones during routine ultrasound for other abdominal conditions or occasionally by palpation of the gallbladder at operation in patients who do not have any abdominal symptoms or have symptoms that are not thought to be due to gallstones.
Symptomatic and uncomplicated cholelithiasis	Symptomatic and uncomplicated cholelithiasis refers to stones in the gallbladder that are associated with biliary colic in the absence of complications such as acute cholecystitis, cholangitis, or gallstone pancreatitis.
Symptomatic and complicated cholelithiasis	Symptomatic and complicated cholelithiasis refers to stones in the gallbladder that are associated with upper abdominal pain, not typical of biliary colic in the presence of complications such as acute cholecystitis, cholangitis, or gallstone pancreatitis.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Cholelithiasis does not have any life-threatening causes.

Common Causes

• Biliary stasis
• Clofibrate
• Combined oral contraceptive pill
• Hemolytic anemia

Management

Shown below is a diagram depicting the management of cholelithiasis according to the Society for Surgery of the Alimentary Tract (SSAT) and data from multiple studies.

Characterize the symptoms: ❑ Asymptomatic ❑ Symptomatic

Asymptomatic: Gallstones identified during ❑ Imaging evaluation of abdominal and pelvic diseases ❑ Palpation of gallbladder at operation

Symptomatic: ❑ Acute abdominal pain

Asymptomatic cholelithiasis

❑ Observation ❑ Expectant management ❑ Prophylactic cholecystectomy

❑ Biliary colic ❑ RUQ or epigastric or substernal pain ❑ Sharp, intermittent and cramping pain ❑ Pain for at least 30 minutes (but <6 hours) ❑ Pain radiating to right shoulder blade ❑ Pain after food intake ❑ Pain not aggravated by movements ❑ Pain associated with nausea, vomiting and diaphoresis ❑ H/o recurrent attacks ranging from hours to years

❑ Acute abdominal pain not typical of biliary colic ❑ RUQ or epigastric or substernal pain ❑ Sharp, severe and steady pain ❑ Pain for >6 hours ❑ Pain radiating to right shoulder blade ❑ Pain after food intake ❑ Pain aggravated by movements ❑ Pain associated with nausea & vomiting ❑ Pain associated with diaphoresis ❑ Pain associated with fever ❑ Pain associated with anorexia

Atypical symptoms: ❑ Diffuse abdominal pain ❑ Retrosternal heart burn ❑ Fluid regurgitation ❑ Belching ❑ Abdominal distension/bloating ❑ Early satiety/fullness after meals

Examine the patient: ❑ No significant findings

Examine the patient: ❑ Febrile ❑ Jaundice ❑ Tachycardia ❑ Tachypnea ❑ Hypotension ❑ Abdominal distension and/or tenderness ❑ Abdominal guarding ❑ Murphy's sign ❑ Altered mental status

Examine the patient

Order laboratory tests: ❑ CBC ❑ BMP ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Amylase ❑ Lipase

Symptomatic & complicated cholelithiasis: Consider evaluation & management of ❑ Cholelithiasis associated complications ± ❑ Choledocholithiasis & choledocholithiasis associated complications

Consider evaluation for alternate diagnosis of abdominal pain

Order transabdominal USG (TAUSG)

Diagnostic criteria: ❑ Biliary colic ❑ No significant findings during PE ❑ Normal CBC, LFT & pancreatic enzymes ❑ Gallstones/biliary sludge during TAUSG

Meets diagnostic criteria: Symptomatic & Uncomplicated cholelithiasis

Does not meet diagnostic criteria: ❑ No gallstones/biliary sludge during TAUSG

Acute pain management: ❑ Ketorolac 30-60 mg IM/IV single dose ❑ Follow with 400 mg ibuprofen/opioids until cholecystectomy

w/ classical biliary colic

w/o classical biliary colic ± atypical symptoms

Poor surgical candidates

Good surgical candidates

Repeat TAUSG in few weeks

Consider evaluation for alternate diagnosis of abdominal pain

Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years/more

Laparoscopic cholecystectomy

Gallstones/biliary sludge during TAUSG

No gallstones/biliary sludge during TAUSG

Diagnostic criteria: ❑ Biliary colic ❑ Abnormal LFT ❑ Normal amylase/lipase ❑ GB visualized during TAUSG ❑ Sphincter of Oddi pressure >40 mmHg in sphincter of Oddi manometry

Suspect sphincter of Oddi dysfunction

❑ Nifedipine or nitrates ❑ ERCP with sphincterotomy

Cholecystokinin stimulated HIDA scan

Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years

Microlithiasis

EUS w/ bile sampling

GBEF >40%

Diagnostic criteria: ❑ Biliary colic ❑ Normal LFT ❑ Normal amylase/lipase ❑ GB visualized during TAUSG ❑ GBEF <40%

Suspect functional gallbladder disorder

Cholecystectomy

No microlithiasis

Consider evaluation for alternate diagnosis of abdominal pain

^†ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic metabolic profile; EUS: Endoscopic ultrasound; ERCP: Endoscopic retrograde cholangiopancreatography; GB: Gall bladder; GBEF: Gall bladder ejection fraction; GGT: Gamma-glutamyl transpeptidase; HIDA scan: Hepatobiliary iminodiacetic acid scan; H/O: History of; IM: Intramuscular; IV: Intravenous; LFT: Liver function test; PE: Physical examination; RUQ: Right upper quadrant; WBC: White blood cell; W/: With; W/:O With out

Do's

• Repeat trans abdominal ultrasound in few weeks in patients suspected of cholelithiasis but neither gallstones or biliary sludge are detected during the initial ultrasound.
• Do laparoscopic cholecystectomy in good surgical candidates as early as possible in order to avoid gallstone related complications.

References

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