Cholelithiasis and Acute Cholecystitis



Cholelithiasis and Acute Cholecystitis


Viriato M. Fiallo



Consuelo Rodriguez is a 40-year-old woman with right upper quadrant pain that started 2 months ago. The pain is precipitated by fatty meals; it begins approximately 60 minutes after eating and lasts for several hours. On occasion, she feels the pain in the inferior aspect of the scapula, the shoulder, and the epigastrium. She frequently feels nauseous with the pain, and she has occasional emesis. Her primary care physician orders an ultrasound of the right upper quadrant that shows multiple stones in the gallbladder. The patient is referred to be evaluated for surgery.



Can cholelithiasis cause any other symptoms?

View Answer

A significant number of patients with cholelithiasis do not have postprandial pain but instead have dyspepsia, vague upper gastric discomfort, or even mildly increased flatulence as primary symptoms (1).



How many types of gallstones are known?

View Answer

There are three types of gallstones: cholesterol, pigmented, and mixed. Approximately 10% of stones are pure cholesterol, 15% are pigmented, and the remaining 75% are mixed (1).



What are the factors in the formation of gallbladder stones?

View Answer

Factors in the formation of cholesterol stones include supersaturation of bile acid micelles, formation of abnormally high-cholesterol-containing biliary vesicles, and ileal disorders or ileal resections. The gallbladder also plays a role in the pathogenesis of cholesterol stones by favoring nucleation (the process by which cholesterol monohydrate crystals form and agglomerate) and crystal growth by abnormal absorption or secretion, by a defective surface pH, or by providing essential nucleating factors including mucin, desquamated cells, bacteria, and reflux intestinal contents (1, 2, 3).



Are stones the only cause of symptoms related to gallbladder disease?

View Answer

No. Functional disorders of the gallbladder and the sphincter of Oddi can give rise to clinical manifestations similar to those of cholelithiasis. These motility disorders have been called chronic acalculous cholecystitis, or gallbladder dyskinesia.

The most specific test for these disorders is cholecystokinin-enhanced cholescintigraphy with assessment of gallbladder ejection fraction. An ejection fraction of less than 35% is considered abnormal (4). Other than biliary dyskinesia, undetectable small stones or cholesterolosis also can be symptomatic. For these patients, duodenal drainage studies demonstrating abnormal bile-containing cholesterol or calcium bilirubinate crystals have been useful. Approximately 80% of patients with abnormal cholecystokinin-cholescintigraphy or abnormal duodenal drainage studies have significant improvement of their symptoms after cholecystectomy (1).



What is the significance of biliary sludge?

View Answer

A study in the 1990s looked at the clinical significance of gallbladder sludge. Diagnosis of gallbladder sludge was made by ultrasound in 286 patients followed up for a mean of 20 months. Although sludge disappeared spontaneously within a relatively short time in 71% of the patients, gallbladder sludge was significant because cholelithiasis or other complications occurred in 19% of the patients. Acute calculus cholecystitis developed in 7.1% of the patients (5).



Are any people more likely to form gallstones than others?

View Answer

An increased incidence of gallstone disease has been observed in elderly patients, certain ethnic groups, women, immediate family members of a patient with cholelithiasis, obese patients, diabetic patients, cirrhotic patients, patients with truncal vagotomy, and patients receiving long-term total parenteral nutrition (1).



What is the natural history of gallstones?

View Answer

Asymptomatic patients with gallstones generally have a benign course. Approximately 2% of asymptomatic patients with gallstones develop symptoms every year. One study of 123 patients with asymptomatic cholelithiasis and an actuarial follow-up period of up to 20 years showed that only 5.7% of these patients developed severe complications, including obstructive jaundice, acute cholecystitis, gallstone ileus, and pancreatitis. Only 13% eventually developed mild symptoms that required elective cholecystectomy (2,6,7).



Should asymptomatic gallstones be treated?

View Answer

It is a general practice not to treat cholelithiasis until symptoms develop. The morbidity and mortality rates of asymptomatic patients treated with observation versus cholecystectomy are similar (8).

Indications for prophylactic cholecystectomy follow (8,9):



  • Children with gallstones: they almost always develop symptoms


  • Sickle cell disease: this condition poses diagnostic difficulties, and approximately 25% of these patients develop symptoms


  • Calcified gallbladder: Approximately 50% of these patients have an associated gallbladder cancer


  • Stones larger than 2.5 cm: they are frequently associated with acute cholecystitis, and a prophylactic cholecystectomy may be warranted


  • Nonfunctioning gallbladder: this indicates advanced disease, and 25% of patients develop symptoms



Is diabetes mellitus an indication for prophylactic cholecystectomy?

View Answer

A prospective study of non-insulin-dependent diabetic patients who were followed for 5 years showed that a cumulative percentage of 10.8% of patients developed symptoms and 4.2% developed complications (9). Another prospective review comparing diabetic and nondiabetic patients who underwent cholecystectomy did not show a difference in the incidence of perforation, wound infection, overall morbidity, or mortality (1). Therefore, in general, prophylactic cholecystectomy in an asymptomatic diabetic patient may not be recommended (2,10). However, it is important to consider individual factors such as age and comorbidities, and surgery may be appropriate in selected asymptomatic diabetic patients.



What are the possible complications of untreated symptomatic cholelithiasis?

View Answer

Possible complications include acute cholecystitis, obstructive jaundice, acute cholangitis, gallstone ileus, and gallstone pancreatitis. Less than 1% of patients with initial complication of cholelithiasis have a fatal outcome during that hospitalization (1).

Now that Mrs. Rodriguez has a good understanding of the pathogenesis of gallstones and the possible complications of cholelithiasis, she wants to know her treatment options.



What are the treatment options for symptomatic cholelithiasis?

View Answer

The treatment options include operative management consisting of open or laparoscopic cholecystectomy, percutaneous cholecystostomy, extracorporeal shock wave lithotripsy (ESWL), oral gallstone dissolution agents (ursodeoxycholic acid), and contact dissolution agents through a percutaneous approach with methyl tert-butyl ether (MTBE).



How effective are the nonoperative options in the management of symptomatic cholelithiasis?

View Answer

ESWL is usually combined with oral bile acid dissolution. Complete stone clearance rates vary from 60% to 90%. The factors that determine the complete clearance of the stones are the isodensity with bile and the computed tomography (CT) score (Hounsfield units below 75). The main causes of failure are acquired stone calcification and impaired gallbladder motility (11). When calculated by actuarial analysis, the probability of stone recurrence has been 5.5% to 7% after 1 year, 11% to 12% after 2 years, 13% after 3 years, 20% after 4 years, and 31% after 5 years (11,12).

Gallbladder emptying is an important factor in the recurrence of gallstones. One study showed that the recurrence rate was 53% at 3 years when the gallbladder ejection fraction was less than 60% but only 13% in patients with an ejection fraction above 60% (13). The cumulative risk of gallstone recurrence by actuarial analysis has been shown, after complete direct contact dissolution with MTBE, to be as follows (14):



  • 1 year, 23%


  • 2 years, 34%


  • 3 years, 55%


  • 4 years, 70%



When are nonsurgical options indicated?

View Answer

These modalities are indicated for symptomatic patients who are poor risks for laparoscopic cholecystectomy. Most protocols for ESWL are limited to symptomatic patients with one to three radiolucent stones with a diameter of 30 mm or less and a functioning gallbladder according to CCK hepatobiliary iminodiacetic acid (CCK HIDA) scan. ESWL is safe and effective for patients with a single stone not more than 20 mm in diameter, but the efficacy for larger single stones and multiple stones is poor (12,14,15). Long-term use of ursodeoxycholic acid is associated with reduced risk of biliary pain and acute cholecystitis (16).



For cholelithiasis, how should symptomatic gallstones be treated?

View Answer

The preferred method of treating symptomatic gallstones is laparoscopic cholecystectomy. It has the advantages of little postoperative discomfort, short hospital stay, and short postoperative disability. This procedure can be performed safely with an overall morbidity that ranges from 3% to 10%, and mortality rates are 0 to 0.1%. Injury to the bile ducts occurs in 0.2% to 0.6% of patients undergoing this procedure. The incidence of complication decreases with increased surgeon experience and with careful attention to laparoscopic surgical technique. The incidence of major bile duct injury can decrease to rates comparable with those of open cholecystectomy.



What are the chances of having calculi in the common bile duct (CBD) in routine cholecystectomy?

View Answer

CBD stones are found in 8% to 15% of patients undergoing cholecystectomy for symptomatic cholelithiasis (1). The incidence seems to be greater in patients older than 60 years of age (25%).



Should intraoperative cholangiography be performed routinely during laparoscopic cholecystectomy?

View Answer

This topic is controversial. Advocates of routine intraoperative cholangiography during laparoscopic cholecystectomy argue that this practice gives a better definition of the anatomy by providing a road map for the surgeon and by identifying anomalous insertion of the cystic duct or other anatomic aberrations of the bile ducts. Only those performing it routinely become proficient in cannulating the cystic duct and in interpreting the fluoroscopic images. Also, a routine intraoperative cholangiogram enables the surgeon to detect an injury to the bile tract early during operation, allowing a prompt repair and reducing the morbidity associated with delayed diagnosis and repair of injuries made to major bile ducts (2,16).

Other surgeons argue against the routine use of cholangiography because they say it is too technical, it wastes time and expense, there are false-positive studies (4%), and it has not been proven that routine intraoperative cholangiography prevents bile duct injury (1,16,17). A retrospective nationwide cohort analysis of Medicare patients undergoing cholecystectomy and a retrospective population-based cohort study looking at the Washington State Hospital discharge database showed that the rate of CBD injury was significantly lower when intraoperative cholangiography was used. Use of intraoperative cholangiography does not, however, completely prevent injuries (18,19).



In what circumstances should an intraoperative cholangiogram be performed?

View Answer

An intraoperative cholangiogram should be performed if there is cholangitis or pancreatitis or a history thereof; if preoperative evaluation shows a dilated or thick CBD; if there are multiple small stones in the gallbladder and the cystic duct; or if the liver function tests are abnormal. An intraoperative cholangiogram is also performed if the surgeon is unable to identify all the structures of the triangle of Calot.

Mrs. Rodriguez agrees to have her gallbladder removed via laparoscopy. While awaiting surgery, she develops severe, constant right upper quadrant pain accompanied by nausea and vomiting. The pain increases rapidly in intensity and is referred to the epigastrium, the right shoulder, and the tip of the scapula.



What is wrong with Mrs. Rodriguez?

View Answer

The patient may have acute cholecystitis or biliary colic. Biliary colic causes pain that reaches a plateau lasting minutes to hours. In patients with acute cholecystitis, the pain persists after several hours and may last days. With time, the pain tends to localize more in the right upper quadrant because of the inflammation irritating the peritoneum (1).



What causes inflammation of the gallbladder in acute cholecystitis?

View Answer

It is believed that the initial inflammatory process is a biochemical phenomenon as opposed to an infectious event. The mediators that have been shown to cause cellular injury and inflammation are the bile acids, lithogenic bile, pancreatic juice, lysolecithin, phospholipase A, and prostaglandins. The bacterial invasion is a secondary process (1).

During physical examination, Mrs. Rodriguez is found to have a tender right upper quadrant with mild guarding and a positive Murphy’s sign. Her temperature is 37.8°C orally. Laboratory examination reveals a leukocyte count of 10,000 per mL, normal electrolyte levels, and a total bilirubin of 1.8 mg per dL. Plain radiograph of the abdomen shows a normal bowel pattern but no stones.



What is Murphy’s sign?

View Answer

A classic physical sign of cholecystitis, Murphy’s sign is elicited by pressing the right upper quadrant with one’s hand and asking the patient to inhale. The sign is present when the patient suddenly stops the inspiratory effort because of the exquisitely painful contact of the inflamed gallbladder with the examiner’s hand.



What is the significance of a palpable mass in the right upper quadrant when acute cholecystitis is suspected?

View Answer

The palpable mass may represent hydrops (mucocele) or a pericholecystic abscess. Hydrops occurs when a gallbladder obstructed by an impacted stone fills with a clear or white mucoid material. The wall usually is not inflamed. The mucoid fluid results from altered secretion of the gallbladder epithelium. Symptoms suggesting cholecystitis may or may not be present (1,2).

In the case of pericholecystic abscess, the patient usually is toxic. Empyema, pus in the lumen of the gallbladder, frequently accompanies this condition. The abscess is secondary to a subacute perforation of the inflamed gallbladder. Intervention in the form of cholecystectomy or cholecystostomy is mandated.



Does the lack of an elevated white blood cell count and high fever rule out acute cholecystitis?

View Answer

No. A recent retrospective study of 100 consecutive patients suspected of having acute cholecystitis who were seen in the emergency department revealed that only Murphy’s sign had a high sensitivity (97.2%) and a high positive predictive value (93.3%) in diagnosing acute cholecystitis compared with biliary scintigraphy (21). These results are similar to those of another retrospective study of 198 patients, which showed that patients with acute cholecystitis (confirmed at surgery) frequently lacked fever and leukocytosis (22).



Does a negative abdominal radiograph rule out gallstones?

View Answer

No. Because gallstones consist largely of the radiolucent cholesterol pigments, only 15% of them are radiopaque. In contrast, kidney stones are 85% radiopaque, a consequence of the higher composition of calcium in kidney stones.



What is the significance of air in the gallbladder revealed by plain radiograph?

View Answer

Emphysema of the gallbladder is a result of infection by gas-producing organisms (e.g., clostridia) and is a surgical emergency. It also may arise from a fistula between the intestine and the gallbladder, allowing air into the latter.



How does ultrasound compare with radionuclide imaging, such as HIDA scan? In which situations is one preferred over the other?

View Answer

Ultrasound is simple, fast, and 95% accurate for demonstrating gallstones (i.e., cholelithiasis) (20). It cannot, however, demonstrate the acute infection of the gallbladder as well as HIDA (accuracy of ultrasound, 79% to 86%) (21). Ultrasound diagnosis of acute cholecystitis is inferred from the ultrasonic images of thickened wall, pericystic fluid, and the presence of intracavitary sludge or stones, intramural gas, and sloughed mucosal membrane.

However, a radionuclide scan has almost 100% sensitivity for diagnosing acute cholecystitis (23). Intravenously (IV) injected isotopes (e.g., HIDA) are secreted into the bile, revealing the biliary tract. The test is reliable with the serum bilirubin level of up to 8 to 10 mg per dL; above those levels, the reliability decreases. The gallbladder is usually visible within 20 to 30 minutes. Failure to reveal the gallbladder implies obstruction of the cystic duct and infection of the organ. Acute cholecystitis is highly likely if the gallbladder is not visible at 1 hour and is certain if the gallbladder is not visible at 4 hours. Acute cholecystitis is mostly a clinical diagnosis; therefore, ultrasound is an adequate test to demonstrate it in a patient with a high clinical suspicion. In patients whose clinical presentation for acute cholecystitis is equivocal or in whom preoperative diagnosis is mandatory because of a significant surgical risk, HIDA scan is more appropriate because of its higher accuracy.



What is the problem with the HIDA scan?

View Answer

It can have false-positive results, especially in critically ill patients on total parenteral nutrition with prolonged fasting and in patients with acute pancreatitis.



Can the specificity of HIDA scan be improved in these circumstances?

View Answer

Yes. Pretreatment with cholecystokinin is helpful in the presence of functional resistance to tracer flow into the gallbladder (24). Administration of IV morphine causes spasm of the sphincter of Oddi, thereby causing reflux of bile with radionuclide in the gallbladder. This technique is recommended when the gallbladder is not visible after 1 hour (24). Morphine also increases the visibility of gallbladder in patients pretreated with cholecystokinin (25).

Mrs. Rodriguez has a mildly elevated total bilirubin.



What does this test result mean in her case?

View Answer

Because the patient does not have a history of liver disease, the two possible explanations are the presence of a stone or stones in the CBD and Mirizzi’s syndrome.



What is Mirizzi’s syndrome?

View Answer

Mirizzi’s syndrome is characterized by obstruction of the common hepatic duct (CHD) or CBD due to contiguous inflammation in the gallbladder or the cystic duct or to compression of the CHD by an impacted large stone in the adjacent cystic duct. The chronic inflammation can result in a stricture. Mild jaundice is present in up to 20% of patients with acute cholecystitis (1). It is usually the result of contiguous inflammation.



Can acute cholecystitis occur in the absence of cholelithiasis?

View Answer

Yes. The condition known as acalculous cholecystitis comprises 4% to 8% of cases of acute cholecystitis (26). Classically, this condition is found in critically ill patients. Recent evidence suggests that the incidence is increasing and that it can be found outside the critical care setting. Most of these patients suffer from atheromatous vascular disease or diabetes mellitus (2). Risk factors include blood volume depletion, prolonged ileus, opioid administration, total parenteral nutrition, severe trauma, sepsis, severe burns, and starvation. The inflammation may arise from prolonged distention of the gallbladder or stasis and inspissation of bile, with subsequent mucosal injury and thrombosis of the vessels of the seromuscular layer of the gallbladder (2). A microangiographic study of 15 patients with acutely inflamed gallbladders showed poor and irregular capillary filling in acalculous cholecystitis versus dilation of arterioles and regular filling of capillaries in calculous cholecystitis (27).



Where do biliary fistulas most commonly form? What are some of the complications?

View Answer

Fistulas are formed frequently between the gallbladder or the CBD and the skin (e.g., biliary cutaneous), duodenum (e.g., cholecystoduodenal), and pleura. Problems with fistulas are infection (e.g., cholangitis from the retrograde infection from the bowel, peritonitis from bile leakage, and infection of the affected organ), electrolyte abnormalities (from the continual loss of electrolytes in the bile, most commonly resulting in hyponatremia), malabsorption syndrome (from the lack of bile, which is critical in the intestinal absorption of fat and fat-soluble vitamins), and gallstone ileus.



What is the radiographic interpretation of air in the gallbladder, dilated proximal loops of bowel, and a calcified mass in the right lower quadrant of the abdomen?

View Answer

The interpretation includes the diagnosis of gallstone ileus, which occurs when a large stone formed in either the gallbladder or the CBD passes through a biliary-enteric fistula. In the intestine, it may cause obstruction at a narrow lumen, most commonly at the ileocecal valve, which causes dilation of the proximal bowel.



What is the proper treatment of gallstone ileus?

View Answer

Gallstone ileus is treated surgically. The gallstone is removed through a small enterotomy. Concomitant cholecystectomy and repair of the fistula are indicated because the patent biliary-enteric fistula may cause recurrent episodes. However, if the patient is too ill, the definitive therapy may be performed later. Enterolithotomy alone has a mortality rate of 5%, in contrast to a mortality rate of 15% for enterolithotomy and cholecystectomy (1).



If inflammation of the gallbladder and the surrounding tissue is anticipated in the setting of acute cholecystitis, is laparoscopic cholecystectomy technically feasible? Is it a good choice?

View Answer

Yes. With increasing experience, laparoscopic cholecystectomy can be performed safely with complication rates and mortality rates comparable with those of open surgery for acute cholecystitis (30, 31, 32). Acute cholecystitis has a higher conversion rate and incidence of accidental opening of the gallbladder than does laparoscopic cholecystectomy for chronic disease (32,33).

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Sep 23, 2016 | Posted by in UROLOGY | Comments Off on Cholelithiasis and Acute Cholecystitis

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