•. CASE 8

A 46-year-old woman presents with a 24-hour history of abdominal pain that began approximately 1 hour after a large dinner. The pain initially began as a dull ache in the epigastrium but then localized in the right upper quadrant (RUQ). She describes some nausea but no vomiting. Since her presentation to the emergency department. the pain has improved significantly to the point of her being nearly pain free. She describes having had similar pain in the past with all previous episodes being self-limited. Her past medical history is significant for type II diabetes mellitus. On physical examination, her temperature is 38.1°C (99°F), and the rest of her vital signs are normal. The abdomen is nondistended with minimal tenderness in the RUQ. Findings from the liver examination appear normal. The rectal and pelvic examinations reveal no abnormalities. Her complete blood count reveals a white blood cell (WBC) count of 13,000/mm’. Serum chemistry studies demonstrate total bilirubin 0.8 mg/dL. direct bilirubin 0.6 mg/dL, alkaline phosphatase 100 UIL, aspartate transaminase (AST) 45 U!L, and alanine transaminase (ALT) 30 U/L. Ultrasonography of the RUQ demonstrates stones in the gallbladder, a thickened gallbladder wall, and a common bile duct diameter of 4.0 mm.

• What is the most likely diagnosis?

• What is the best therapy?

• What are the complications associated with this disease process?

ANSWERS TO CASE 8: Gallstone Disease

Sumniarv: A 46-year-old woman presents with a 1-day history of RUQ abdominal pain and a physical examination and laboratory findings suggestive of gallstone disease.

• I)iagnosis: Cholecystitis, likely acute and chronic.

• Best therapy: Laparoscopic cholecystectomy is the preferred treatment for all patients with a reasonable life expectancy and no prohibitive

risks for general anesthesia and abdominal surgery.

• Complications: Complications from gallstone disease include acute and chronic cholecystitis, pancreatitis. choledocholithiasis, cholangitis. and gallstone ileus.

Analysis

Objectives

1. Know the etiology of gallstone disease and learn the differences among biliary colic, acute cholecystitis, and chronic cholecystitis.

2. Know the basic diagnostic and therapeutic plans for patients with gallstone disease.

3. Become aware of the complications arising from gallstone disease.

Considerations

This patient provides a good history of recurrent RUQ abdominal pain episodes following meals, consistent with biliary colic. Although she demonstrates minimal tenderness to palpation in her right upper abdomen on physical examination, the elevated leukocyte count and ultrasound findings of gallbladder wall thickening are consistent with acute or chronic cholecystitis. If this patient had a normal WBC count and an ultrasound examination demonstrating stones in the gallbladder and no other abnormalities, the presentation would be consistent with biliary colic, which can be treated by elective cholecystectomy. For cholecystitis, the appropriate treatment consists of hospital admission, administration of intravenous antibiotics, and laparoscopic cholecystectomy prior to discharge from the hospital.

APPROACH TO GALLSTONE DISEASE

Definitions

Biliary colic: characterized by waxing and waning, poorly localized postprandial upper abdominal pain radiating to the back and normal laboratory evaluations of liver functions. It is caused by cholecystokinin-stimulated gallbladder contraction, following food ingestion. The condition is generally produced by gallstone obstruction at the gallbladder neck or, less commonly. by gallbladder dysfunction.

Acute cholecystitis: In 95% of patients. acute cholecystitis results from a stone or stones obstructing the cystic duct. Bacterial infection is thought to occur via the lymphatics, with the most commonly found organisms being Escherichia coil, Kiebsielia, Proteus, and Streptococcus faecaiis. Patients generally present with persistent RUQ pain, with or without fever, gallbladder tenderness, leukocytosis, and often mild, nonspecific elevated liver enzyme levels, which may or may not indicate common bile duct stones. Treatment includes hospital admission, administration of intravenous fluids, nothing by mouth, antibiotics directed at the organisms just listed, and cholecystectomy during the hospitalization.

Acalculous cholecystitis: Gallbladder inflammation caused by biliary stasis (in 5% of patients with acute cholecystitis) leading to gallbladder distension, venous congestion, and decreased perfusion: it nearly always occurs in patients hospitalized with a critical illness.

Chronic cholecystitis: Results from repeated bouts of biliary colic andlor acute cholecystitis leading to gallbladder wall inflammation and fibrosis. The patient may present with persistent or recurrent localized RUQ pain without fever or leukocytosis. Sonography may demonstrate a thickened gallbladder wall or a contracted gallbladder.

Cholangitis: Infection within the bile ducts, most commonly because of complete or partial obstruction of the bile ducts by gallstones or strictures. The classic Charcot’s triad (RUQ pain, jaundice, and fever) is seen in only 70% of patients. This condition may lead to life-threatening sepsis and multiple-organ failure. Treatment consists of antibiotic therapy and supportive care: in cases of severe cholangitis. endoscopic decompression of the bile duct by endoscopic retrograde cholangiopancreatography (ERCP) or surgery is indicated.

Right upper quadrant ultrasonography: Ninety eight to ninety nine percent sensitivity in identifying gallstones in the gallbladder. The examination is also useful for measuring the diameter of the common bile duct, which can indicate the possible presence of stones in the common bile duct (choledocholithiasis). When present. common bile duct stones are visualized less than 50% of the time with this imaging modality.

Biliary scintigraphy: The study of gallbladder function and hiliary patency using an intravenous radiotracer. Normally the liver is visualized, followed by the gallbladder. followed by emptying of the radiotracer into the duodenum. Nonvisualization of the gallbladder in a patient with RUQ pain indicates gallbladder dysfunction caused by acute or chronic cholecystitis.

Endoscopic retrograde cholangiopancreatography: Endoscopic common

bile duct cannulation and direct injection of contrast material to visualize the duct. An endoscopic sphincterotomy in the duodenum during the procedure may facilitate bile drainage and the clearance of bile duct stones, which is especially useful in treating cholangitis and choledocholithiasis. The procedure requires sedation and may be associated with complication rates of 8% to 10%.

Pathophysiology

At least 16 million Americans have gallstones, and 800,000 new cases occur each year. Gallstones are categorized as either cholesterol stones or pigmented stones. Cholesterol stones are most common and form as the result of the combined effects of cholesterol supersaturation in the bile and gallbladder dysfunction. Only a small fraction (15—20%) of patients with gallstones develop symptoms. Although it is unknown why some patients with gallstones develop symptoms whereas others do not, it is clear that those who develop symptoms are at risk for the subsequent development of complications, including acute and chronic cholecystitis,c holedocholithiasis, pancreatiis, and cholangitis.

Patient Evaluation and Treatment

The evaluation in every patient should consist of a history, a physical examination, a complete blood count, liver function studies, a serum amylase determination, and RUQ ultrasonography (Table 8—1). It is important to differentiate biliary colic from complicated gallstone disease, such as acute or chronic cholecystitis, choledocholithiasis, cholangitis, and biliary pancreatitis, because the management varies ftr these conditions. For example. a patient with choledocholithiasis may present with symptonis identical to those of biliarv colic, but the condition may be differentiated on the basis of an elevation in serum liver enzyme levels and dilation of the common bile duct by ultrasound. In contrast to patients with biliary colic, who are treated by elective cholecystectomy, patients with choledocholithiasis require in-hospital observation for the development of cholangitis and early endoscopic clearance of common bile duct stones, in addition to cholecystectomy. A major goal in patient evaluation is to make an accurate diagnosis without using unnecessary imaging and invasive diagnostic studies. Choledocholithiasis should be suspected it the RUQ ultrasound findings include a common bile duct diameter >5 mm in the presence of elevated liver enzyme levels. Gallstone pancreatitis should be considered in the presence of significantly elevated amylase and lipase values.

Sometimes, acute and chronic cholecystitis may be difficult to differentiate clinically because in both cases patients may have localized tenderness over the gallbladder. When this situation arises, patients should be treated as if they had acute cholecystitis. The treatment for both acute and chronic cholecystitis is cholecystectomy. The operation of choice is a laparoscopic cholecystectomy with or without cholangiography (radiopaque dye injected into the common bile duct and a radiograph taken). Some surgeons selectively perform cholangiograms if the common bile duct is dilated and liver enzyme levels are elevated. Other surgeons obtain cholangiograms with every laparoscopic cholecystectomy performed. Patients with gallstone pancreatitis are treated with bowel rest and intravenous hydration. When the pancreatitis resolves clinically, a laparoscopic cholecystectomy can be done. Generally, patients with uncomplicated biliary pancreatitis should undergo cholecystectomy during the same hospitalization. When cholecystectomy is delayed, 25% to 30% of patients may develop recurrent bouts of pancreatitis within a

6-week period.

Comprehension Questions

[8.1 j A 65-year-old woman presents to the emergency department with postprandial RUQ pain, nausea, and emesis over the last 12 hours. The pain is persistent and radiates to her back. She is afebrile, and her abdomen is tender to palpation in the RUQ. Sonography demonstrates cholelithiasis, gallbladder wall thickening, and a dilated common bile duct meastiring 12mm. Laboratory studies reveal the following values: WBC count 13,000/mm’, AST 220 UIL, ALT 240 UIL, alkaline phosphatase

385 U/L, and direct bilirubin 4.0 mg/dL. Which of the following is the most appropriate treatment at this time?

A. Admit the patient to the hospital, provide intravenous hydration, and check hepatitis serology values.

B. Admit the patient to the hospital and perform a laparoscopic cholecystectomy.

C. Admit the patient to the hospital, provide intravenous hydration. begin antibiotic therapy, and recommend ERCP.

D. Provide pain medication in the emergency department and ask the patient to follow up in the clinic.

[8.21 A 28-year-old woman undergoing an obstetric ultrasound during the second trimester of pregnancy is found to have gallstones in her gallbladder. She claims to have had indigestion with frequent belching throughout her pregnancy. Which of the following is the most appropriate treatment?

A. A low-fat diet until the end of her pregnancy and then a postpartum laparoscopic cholecystectomy

B. Elective laparoscopic cholecystectomy during the second trimester

C. Follow-up after completion of her pregnancy

D. Open cholecystectorny during the second trimester

(8.3J Which of the following findings is most consistent with the diagnosis of acute cholecystitis?

A. Fever, intermittent RUQ pain, and jaundice

B. Persistent abdominal pain. RUQ tenderness, and leukocytosis

C. Intermittent abdominal pain and minimal tenderness over the gallbladder

D. Epigastric and back pain

[8.4] A 69-year-old man presents with confusion, abdominal pain, shaking chills, a rectal teniperature of 34°C (94°F), and jaundice. An abdominal radiograph shows air in the biliary tree. Which of the following is the most likely diagnosis?

A. Acute cholangitis

B. Acute pancreatitis

C. Acute cholecystitis

D. Acute appendicitis

Answers

[8.11 C. Admission to the hospital, administration of intravenous fluids and antibiotics, and ERCP. This patient’s presentation is highly suggestive of cholangitis, with thc presence of a significant elevation in her liver enzyme levels, common bile duct dilation, and tenderness in the RUQ.

[8.2] C. Reevaluation after the completion of pregnancy is appropriate for this patient, who has stones in her gallbladder and symptoms that are most likely unrelated to gallstones and may be pregnancy induced.

[8.3] B. Persistent abdominal pain. RUQ tenderness, and leukocytosis indicate acute cholecystitis. Choice A is most consistent with cholangitis; choice C is typical of biliary colic, and choice D is consistent with acute pancreatitis.

18.4] A. Elderly patients over age 65 who present with fever (or hypothermia). jaundice, abdominal pain, and shaking chills often have acute cholangitis (purulent infection of the biliary tract). The presence of air in the biliary tree is consistent with this illness. This is a life-threatening condition and often requires urgent surgical or endoscopic decompression of the biliary system, in addition to aggressive supportive care and broadspectrum antibiotic therapy.

CLINICAL PEARLS

Cholecystectomy is generally not indicated unless there is a clear link between the patient’s symptoms and gallstones or if there is objective evidence of gallbladder dysfunction (e.g., a thickened gallbladder wall on ultrasonography, nonvisualization of the gallbladder on biliary scintigraphy) or gallstone-related complications.

In general, the treatment of cholecystitis is hospitalization, administration of intravenous antibiotics, and a laparoscopic cholecystectomy prior to discharge from the hospital.

Choangitis, which can be diagnosed with Charcot’s triad— RUQ pain, jaundice, and fever—is life-threatening. Treatment consists of antibiotics therapy, supportive care, and, in cases of severe cholangitis biliary duct, decompression via ERCP.

Choledocholithiasis should be suspected if the RUQ ultrasound findings include a common bile duct diameter >5 mm in the presence of elevated liver enzyme levels.