Cholelithiasis (Gall Stone)

Background:

Cholelithiasis involves the presence of gallstones, which are concretions that form in the biliary tract, usually in the gallbladder. Choledocholithiasis refers to the presence of 1 or more gallstones in the common bile duct (CBD). Treatment of gallstones depends on the stage of disease.

Signs and Symptoms:

Gallstone disease may be thought of as having the following 4 stages:

Lithogenic state, in which conditions favor gallstone formation
Asymptomatic gallstones
Symptomatic gallstones, characterized by episodes of biliary colic
Complicated cholelithiasis

Symptoms and complications result from effects occurring within the gallbladder or from stones that escape the gallbladder to lodge in the CBD.

Characteristics of Biliary Colic Include the Following:

Sporadic and unpredictable episodes
Pain that is localized to the epigastrium or right upper quadrant, sometimes radiating to the right scapular tip
Pain that begins postprandially, is often described as intense and dull, typically lasts 1-5 hours, increases steadily over 10-20 minutes, and then gradually wanes
Pain that is constant; not relieved by emesis, antacids, defecation, flatus, or positional changes; and sometimes accompanied by diaphoresis, nausea, and vomiting
Nonspecific symptoms (eg, indigestion, dyspepsia, belching, or bloating)

Patients with the lithogenic state or asymptomatic gallstones have no abnormal findings on physical examination.

Distinguishing uncomplicated biliary colic from acute cholecystitis or other complications is important.

Key Findings That May Be Noted Include the Following:

Uncomplicated biliary colic – Pain that is poorly localized and visceral; an essentially benign abdominal examination without rebound or guarding; absence of fever
Acute cholecystitis – Well-localized pain in the right upper quadrant, usually with rebound and guarding; positive Murphy sign (nonspecific); frequent presence of fever; absence of peritoneal signs; frequent presence of tachycardia and diaphoresis; in severe cases, absent or hypoactive bowel sounds

The presence of fever, persistent tachycardia, hypotension, or jaundice necessitates a search for complications, which may include the following:

Cholecystitis
Cholangitis
Pancreatitis
Other systemic causes

Diagnosis:

Patients with uncomplicated cholelithiasis or simple biliary colic typically have normal laboratory test results; laboratory studies are generally not necessary unless complications are suspected. Blood tests, when indicated, may include the following:

Complete blood count (CBC) with differential
Liver function panel
Amylase
Lipase

Imaging modalities that may be useful include the following:

Abdominal radiography (upright and supine) – Used primarily to exclude other causes of abdominal pain (eg, intestinal obstruction)
Ultrasonography – The procedure of choice in suspected gallbladder or biliary disease
Endoscopic ultrasonography (EUS) – An accurate and relatively noninvasive means of identifying stones in the distal CBD
Laparoscopic ultrasonography – Promising as a potential method for bile duct imaging during laparoscopic cholecystectomy
Computed tomography (CT) – More expensive and less sensitive than ultrasonography for detecting gallbladder stones, but superior for demonstrating stones in the distal CBD
Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) – Usually reserved for cases in which choledocholithiasis is suspected
Scintigraphy – Highly accurate for the diagnosis of cystic duct obstruction
Endoscopic retrograde cholangiopancreatography (ERCP)
Percutaneous transhepatic cholangiography (PTC)