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| __NOTOC__
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| {{CMG}}; {{AE}} {{VR}}
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| ==Cholelithiasis==
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| ===Definitions===
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| {|class="wikitable"
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| ! Terms!! Definitions
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| | 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.
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| | Microlithiasis (biliary sludge)|| Microlithiasis (biliary sludge) are crystals and stones in the gallbladder that are too small to see with the naked eye.
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| | 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.
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| | 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.
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| | 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.
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| ===Causes===
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| ====Life Threatening Causes====
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| Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
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| ====Common Causes====
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| ===Management===
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| {{familytree/start |summary=Cholelithiasis}}
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| {{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br> ❑ Asymptomatic <br> ❑ Symptomatic </div> }}
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| {{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | }}
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| {{familytree | | | | | | | | | B01 | | | | | | B02 | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Asymptomatic:'''<br> Gallstones identified during<br> ❑ Imaging evaluation of abdominal and pelvic diseases<br> ❑ Palpation of gallbladder at operation </div>|B02=<div style="float: left; text-align: left; line-height: 150% ">'''Symptomatic:'''<br> ❑ Abdominal pain </div>}}
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| {{familytree | | | | | | | | | |!| | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | | C01 | | |,|-|-|-|^|v|-|-|-|.| | | | |C01='''Asymptomatic cholelithiasis'''}}
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| {{familytree | | | | | | | | | |!| | | |!| | | | |!| | | |!| | | |}}
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| {{familytree | | | | | | | | | D01 | | D02 | | | D03 | | D04 | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">❑ Observation<br>❑ Expectant management<br>❑ Prophylactic cholecystectomy</div>|D02=<div style="float: left; text-align: left; line-height: 150% ">❑ Biliary colic<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ Right upper quadrant or epigastric or substernal pain
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| :❑ Sharp, intermittent and cramping pain
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| :❑ Pain for at least 30 minutes (but <6 hours)
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| :❑ Pain radiating to right shoulder blade
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| :❑ Pain after food intake
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| :❑ Pain not aggravated by movements
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| :❑ Pain associated with nausea, vomiting and diaphoresis
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| :❑ H/o recurrent attacks ranging from hours to years</div></div> </div>|D03=<div style="float: left; text-align: left; line-height: 150% ">❑ Abdominal pain not typical of biliary colic<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| :❑ Right upper quadrant or epigastric or substernal pain
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| :❑ Sharp, severe and steady pain
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| :❑ Pain for >6 hours
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| :❑ Pain radiating to right shoulder blade
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| :❑ Pain after food intake
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| :❑ Pain aggravated by movements
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| :❑ Pain associated with nausea & vomiting
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| :❑ Pain associated with diaphoresis
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| :❑ Pain associated with fever
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| :❑ Pain associated with anorexia</div></div> </div>|D04=<div style="float: left; text-align: left; line-height: 150% ">'''Atypical symptoms:'''<br>❑ Diffuse abdominal pain<br>❑ Retrosternal heart burn<br>❑ Fluid regurgitation<br>❑ Belching<br>❑ Abdominal distension/bloating<br>❑ Early satiety/fullness after meals</div>}}
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| {{familytree | | | | | | | | | | | | | |!| | | | |!| | | |!| | | |}}
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| {{familytree | | | | | | | | | | | | | E01 | | | E02 | | E03 | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<br>❑ No significant findings</div>|E02=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<br>❑ Febrile<br>❑ Jaundice<br>❑ Tachycardia<br>❑ Tachypnea<br>❑ Hypotension<br>❑ Abdominal distension and/or tenderness<br>❑ Abdominal guarding<br>❑ Murphy's sign<br>❑ Altered mental status </div>|E03=Examine the patient}}
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| {{familytree | | | | | | | | | | | | | |!| | | | |!| | | |!| | | |}}
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| {{familytree | | | | | | | | | | | | | F01 | | | F02 | | F03 | | | | |F01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase</div>|F02='''Symptomatic & complicated cholelithiasis:'''<br>Consider evaluation of cholelithiasis associated complications ± choledocholithiasis & choledocholithiasis associated complications|F03=Consider evaluation for alternate diagnosis of abdominal pain}}
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| {{familytree | | | | | | | | | | | | | |!| | | | |!| | | |!| | | |}}
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| {{familytree | | | | | | | | | | | | | G01 | | | G02 | | G03 | | | | | |G01='''Order transabdominal USG (TAUSG)'''|G02=<div style="float: left; text-align: left; line-height: 150% ">'''Consider:'''<br>❑ CBC<br>❑ BMP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase<br>❑ TAUSG<BR>❑ HIDA<BR>❑ EUS/MRCP<BR>❑ ERCP<BR>❑ Blood C & S</div>|G03=<div style="float: left; text-align: left; line-height: 150% ">'''Consider:'''<br>❑ CBC<br>❑ BMP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase<br>sphincter of Oddi dysfunction Urine analysis<br>❑ EKG<br>❑ CXR<br>❑ Esophageal manometry<br>❑ UGI endoscopy<br>❑ CT abdomen</div>}}
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| {{familytree | | | | | | | | | | | | | |!| | | | |!| | | |!| | |}}
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| {{familytree | | | | | | | | | | | | | H01 | | | H02 | | H03 | | | |H01=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic criteria:'''<br>❑ Biliary colic<br>❑ No significant findings during PE<BR>❑ Normal CBC, LFT & pancreatic enzymes<br>❑ Gallstones/biliary sludge during TAUSG </div>|H02=Manage accordingly|H03=Manage accordingly}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | |}}
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| {{familytree | | | | | | | | | I01 | | | | | | I02 | | | |I01='''Meets diagnostic criteria:'''<br>'''Symptomatic & Uncomplicated cholelithiasis'''|I02='''Does not meet diagnostic criteria:'''<br>❑ No gallstones/biliary sludge during TAUSG}}
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| {{familytree | | | | | | | | | |!| | | | | |,|-|^|-|.| | |}}
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| {{familytree | | | | | | | | | J01 |-|.| | J02 | | J03 | |J01=<div style="float: left; text-align: left; line-height: 150% ">Acute pain management
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| :❑ Ketorolac 30-60 mg IM/IV single dose
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| :❑ Follow with 400 mg ibuprofen/opioids until cholecystectomy</div>|J02=w/ classical biliary colic|J03=w/o classical biliary colic ± atypical symptoms}}
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| {{familytree | | | | | | |,|-|-|^|.| |!| | |!| | | |!| |}}
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| {{familytree | | | | | | K01 | | K02 |!| | K03 | | K04 | |K01=Poor surgical candidates|K02=Good surgical candidates|K03=Repeat TAUSG in few weeks (especially for <3 mm stones)|K04=Consider evaluation for alternate diagnosis of abdominal pain}}
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| {{familytree | | | | | | |!| | | |!| |!| |,|^|-|-|-|.|}}
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| {{familytree | | | | | | L01 | | L02 |`|-| L03 | | L04 |-|L05|-|L06|-|L07|L01=Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years/more|L02=Laparoscopic cholecystectomy (as early as possible to avoid gallstone related complications)|L03=Gallstones/biliary sludge during TAUSG|L04= No gallstones/biliary sludge during TAUSG|L05=<div style="float: left; text-align: left; line-height: 150% ">❑ Biliary colic<br>❑ Abnormal LFT<BR>❑ Dilated CBD in TAUSG<BR>❑ Sphincter of Oddi pressure >40 mmHg in sphincter of Oddi manometry</div>|L06='''Sphincter of Oddi dysfunction'''|L07=ERCP with endoscopic sphincterotomy}}
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| {{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | | | | | M01 | | |M01=Cholecystokinin stimulated HIDA scan}}
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| {{familytree | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | | |}}
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| {{familytree | | | | | N01 |-| N02 |-| N03 |-| N04 | | N05 |-|N06|-|N07|N01=Ursodeoxycholic acid 10/14 mg/kg/day before bed time for 1-2 years|N02='''Microlithiasis'''|N03=EUS|N04=GBEF >40%|N05=GBEF <40%|N06='''Functional Gallbladder disorder'''|N07=Chloecystectomy}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | O01 | | | | | | | | | | | |O01=Consider evaluation for alternate diagnosis of abdominal pain}}
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