Gallbladder Disease (cholelithiasis, biliary colic, cholecystitis, choledocholithiasis, cholangitis)

A lot of the western world have stones in their gallbladders (cholelithiasis) but for the most part they just grumble along with no trouble at all.

  1. Cholelithiasis – Gallstones just hanging out, not causing any problems
  2. Biliary colic – happens after a fatty meal, the GB contracts and pushes stones into the cystic duct but when the duct relaxes the stone rolls back into the GB. The pain is entirely visceral and generally lasts <6h. There should be no fever or chills.
  3. Cholecystitis – inflammation of the GB. It’s biliary colic that just doesn’t go away. The pain lasts longer than 6h and is usually associated with nausea/vomiting, fever and right upper quadrant pain.
  4. Choledocholithiasis – gallstones in the common bile duct. Usually secondary to cholelithiasis, but can be a primary stone in cases of bile stasis or recurrent infection of the biliary tree. Usually have abnormalities in liver enzymes and pain but no fever.
    The 2 major complications are 1) Cholangitis and 2) Acute pancreatitis.
  5. Cholangitis – infection/inflammation of the biliary tree (infected bile or gallstone), secondary to an impacted stone or stricture(s).
    Do an ultrasound. Start antibiotics (common bugs are a mix of gram +/- and anaerobes = E. coli, enterococcus, bactericides). Ciprofloxacin or a combination of ampicillin, ceftazimide and metronidazole.
    Make sure that the person receives some fluid resuscitation to help with the hypoperfusion
    Charcot’s triad: fever, RUQ pain, jaundice
    Reynold’s pentad: hypoperfusion, decreased level of consciousness (SHOCK!!!)
    DDx

    • Biliary leaks
    • Liver abscess
    • Infected choledochal cysts
    • Cholecystitis
    • Mirizzi syndrome
    • Right lower lobe pneumonia/empyema

Lab values

Biliary Colic Cholecystitis Choledocholithiasis Cholangitis Gallbladder Pancreatitis
WBC  –  ↑ ↑↑  ↑
AST  ↑
ALT
Total Bili  – ↑↑ ↑↑
Direct Bili ↑↑ ↑↑↑ ↑↑
ALP ↑↑ ↑↑↑ ↑↑
GGT ↑↑ ↑↑↑ ↑↑
Lipase ↑↑↑ (>3x)
Amylase ↑↑↑ (>3x)
Treatment Cholecystectomy Cholecystectomy ERCP +/- Cholecystectomy Fluid resuscitation ERCP + Cholecystectomy Fluid resuscitation ERCP + Cholecystectomy

Liver Enzymes (hepatic vs cholestatic patterns)

 

Liver enzymes can be elevated for a number of reasons, but the first step in an approach is to determine if the enzymes are in a hepatic pattern or cholestatic pattern. It is also very important to realize that Alk phos, GGT, ALP, and AST are liver enzymes, but they don’t give an indication of function; for that you need to look at INR and bilirubin.

Z tracking for paracentesis

Z-tracking is a way to minimize fluid leakage after performing a paracentesis. The skin is slowly pulled down while the needle is advanced in 5 mm increments, aspirating as you go. If it is a therapeutic paracentesis, use a large bore needle (14) to reduce the amount of time it takes to drain.

Indications for paracentesis

  • New onset ascites
  • Hospitalization of a patient with ascites
  • Clinical deterioration of an inpatient or outpatient with ascites
    • Fever
    • Abdominal pain
    • Abdominal tenderness
    • Hepatic encephalopathy
    • Peripheral leukocytosis
    • Deterioration in renal function
    • Acidosis

Routine tests

  • Cell count and differential
  • Albumin concentration (you then compare this to serum albumin)
  • Total protein concentration
  • Culture

Contraindications

DIC, primary fibrinolysis

serum to aspires gradient (SAAG)

Used to identify the presence of portal hypertension

SAAG = Serum albumin – Ascites albumin

≥11 g/L: portal hypertension
<11 g/L: not portal hypertension
If heart failure is the cause, the gradient can be narrowed by diuresis, but in cirrhosis the gradient does not change unless the portal pressure drops significantly

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