1. EVALUATION AND
TREATMENT OF
GALLBLADDER
DISEASE
Dr. Kellen “Gallstone”

2. EVALUATION AND
TREATMENT OF
GALLBLADDER
DISEASE
Dr. Kellen “Gallstone”
Not to be confused with Galster Stone’s

3. OBJECTIVES
 Understand disease pathology and presentation
 Diagnostic modalities
 Treatment options
 Improve interdepartmental relations(buy them beer!)

4. THE BASICS

5. VOCAB
 Biliary Colic – painful passage of gallstones
 McMurphy Sign – inspiratory arrest during deep palpation to RUQ
 Cholesterol Stone – assoc. ↑ age, female, obese, rapid weight
loss, CF, parity (by far the most common)
 Pigmented Stone – contain calcium 2/2 chronic intravascular
hemolysis (sickle cell, spherocytosis) or biliary infections
 Magnetic resonance cholangiopancreatography (MRCP)
 Endoscopic Retrograde Cholangiopancreatography (ERCP)

6. ANATOMY

7. CHOLELITHIASIS
Gallstones in the gallbladder are asymptomatic in 80% of patients.
Clinically manifests as biliary colic during passage of a stone or
ductal blockage 2/2 stone.
 Exam
 Most pt present with postprandial upper abdominal pain, occasionally radiates
to the right subscapular are or the epigastrium
 Acute onset of pain with gradual relief, associated with nausea/vomiting,
dyspepsia and fatty food intolerance
 Mild tenderness to palpation w/o guarding or rebound
 Diagnosis
 LFT are normal, US Shows gallstones with an 85-90% sensitivity
 Oral cholecystography ipanoic acid is 95% sensitive, useful when gallbladder
can not be visualized
 Plain film only visualizes 10% of gallstones

8. CHOLELITHIASIS ULTRASOUND

9. CHOLELITHIASIS
 Treatment
 Pain relief w/ antispasmodics, NSAIDs and Narcotics
 Correction of dehydration and electrolyte imbalances 2/2 N/V
 Antiemetics
 Avoidance of fatty foods
 PO bile acid chenodeoxycholate or ursodeoxycholate to dissolve stones
 Elective outpatient cholecystectomy

10. EARLY VS LATE
CHOLECYSTECTOMY
 Mortality
 Pancreatitis
 Morbidity (other)
 Hospital Stay

11. CHOLEDOCHOLITHIASIS
Gallstones in the common bile duct
 Exam
 RUQ pain, episodic colic, fever, occasional jaundice and occasional
pancreatitis
 Diagnosis
 ↑ Alkaline phosphatase and total bilirubin
 Ultrasound shows dilated common bile duct
 MRCP - useful for visualizing ductal involvement

12. CHOLEDOCHOLITHIASIS ULTRASOUND

13. CHOLEDOCHOLITHIASIS ULTRASOUND

14. CHOLEDOCHOLITHIASIS
 Treatment
 ERCP w/ sphincterotomy for stone removal
 Followed later by semi-elective cholecystectomy

15. CHOLECYSTITIS
Inflammation of the gallbladder 2/2 blockage of the cystic duct (2-12%
acalculous). Gallbladder becomes distended, inflamed, superinfected
and possible gangrenous.
 Exam
 Pain may initially be described as colicky but will progress to constant
 Murphy’s Sign, fever, leukocytosis, possible guarding or rebound tenderness
 More sever and longer than those of biliary colic, w/ N/V
 Diagnosis
 Ultrasound demonstrates stones, thickened gallbladder wall, +/- pericholecystitis
fluid, biliary sludge, w/ + Ultrasonographic murphy's sign
 HIDA scan when Ultrasound in equivocal, non-visualized gallbladder/cystic duct 1
hour after receiving IDA (iminodiacetic acid) is highly suggestive of Cholecystitis.
 CT scan is 92% sen. and 99% spec.
 LFTs and WBCs normal to mildly elevated

16. CHOLECYSTITIS

17. CHOLECYSTITIS

18. CHOLECYSTITIS
 Treatment
 Correction of dehydration and electrolyte imbalances 2/2 N/V
 Nasogastric suctioning to decompress the stomach ↓ biliary secretions
 Surgical consult
 Pain control with Narcotics
 Hospitalize and begin a single 2nd or 3rd generation cephalosporin
 Cholecystectomy is definitive treatment or percutaneous drainage in an
unstable patient.
 50% resolve spontaneously, hemodynamically stable patients with significant
medical problems can be managed medically for 4-6 before semi-elective
surgery

19. ACUTE “BACTERIAL” CHOLANGITIS
Infection of the biliary tree secondary to common bile duct
obstruction/stasis.
 Exam
 Charcot’s Triad: RUQ pain, Jaundice, Febrile (seen in 70% of patients)
 Reynolds’ Pentad: RUQ pain, Jaundice, Febrile + Shock and AMS
 Risk Factors
 Caused by gram (-) enterics: E. coli, Klebsiella, Enterococcus, Bacteroides,
and Enterobacter
 Gallstones (85%), bile duct stricture, ampullary carcinoma, pancreatic
pseudocyst.
 Diagnosis
 Leukocytosis (80%), hyperbilirubinemia (80%), ↑ Alkaline Phosphatase

20. CHOLANGITIS
 Treatment
 Fluid resuscitation
 Blood Cx
 Broad-Spectrum IV Abx: ampicillin-sulbactam (Unasyn), piperacillin-
tazobactam (Zosyn), ceftriaxone + metronidazole, meropenem, or ampicillin +
gentamycin + metronidazole
 Consider ICU admission
 Consult Surgery, GI, or IR
 Early intervention w, ERCP, percutaneous transhepatic cholangiography
(THC), or open decompression

21. RARE AND OR SERIOUS
 Emphysematous cholecystis - If air is seen in the gallbladder on
abdominal x-ray or ultrasound this is a life threatening condition
found in older men classically associated w/ DM and caused by
Clostridium perfringes.
 Porcelain Gallbladder – linear or punctuate calcifications w/in the
gallbladder wall on plain film. High incidence of carcinoma. Referral
for elective cholecystectomy. Commonly women in their 50s.
 Acalculous cholecystitis - Inflammation of the gallbladder 2/2
blockage of the cystic duct by pathology other than stones. Tumor,
lymphadenopathy, fibrosis, parasites, and kinking of the duct.
 AIDS Cholangiopathy – associated with CD4 >200. These patients
experience bile duct strictures, papillary stenosis, and sclerosing
cholangitis. The infection are caused by CMV, Cryptosporidium,
microsporidia, or Mycobacteria avium. Presentation and treatment
are similar to cholangitis.

22. RARE AND OR SERIOUS
 Sclerosing Cholangitis – an idiopathic inflammatory disorder
affecting the biliary tree. There is diffuse fibrosis and narrowing of
the intrahepatic and extrahepatic bile ducts. Commonly
associated with Ulcerative Colitis w/ 25% of cases appearing to
be an isolated disorder.
 Perforation
 Gangrene
 Fistulization
 Sepsis
 Abscess

23. BLOGOSPHERE

24. A 72-year-old man with known Type 2 diabetes mellitus presents
with severe right upper quadrant abdominal pain radiating to his
back. He denies recent illness or surgery. Physical examination
reveals fever and tachycardia, with tenderness in the right upper
quadrant but no peritoneal signs. The patient is not icteric, and his
pulmonary examination is unremarkable. Radiographs are ordered
(image below). What is the most appropriate management?
A) Obtain emergent surgery consultation
B) Obtain RUQ ultrasonography
C) Order complete white count and differential, electrolytes, and
liver function tests
D) Order CT of the abdomen
E) Start fluid resuscitation

26. A 72-year-old man with known Type 2 diabetes mellitus presents
with severe right upper quadrant abdominal pain radiating to his
back. He denies recent illness or surgery. Physical examination
reveals fever and tachycardia, with tenderness in the right upper
quadrant but no peritoneal signs. The patient is not icteric, and his
pulmonary examination is unremarkable. Radiographs are ordered
(image below). What is the most appropriate management?
A) Obtain emergent surgery consultation
B) Obtain RUQ ultrasonography
C) Order complete white count and differential, electrolytes, and
liver function tests
D) Order CT of the abdomen
E) Start fluid resuscitation

27. A 72-year-old man with known Type 2 diabetes mellitus presents
with severe right upper quadrant abdominal pain radiating to his
back. He denies recent illness or surgery. Physical examination
reveals fever and tachycardia, with tenderness in the right upper
quadrant but no peritoneal signs. The patient is not icteric, and his
pulmonary examination is unremarkable. Radiographs are ordered
(image below). What is the most appropriate management?
A) Obtain emergent surgery consultation
B) Obtain RUQ ultrasonography
C) Order complete white count and differential, electrolytes, and
liver function tests
D) Order CT of the abdomen
E) Start fluid resuscitation

29. Answer:
This patient has emphysematous cholecystitis, an acute infection of
the gallbladder caused by gas-producing organisms. It frequently
affects older men. A significant percentage of patients with this
condition have underlying diabetes mellitus, and 28% to 80% have
gallstones. Clostridial spp. E coli, and Klebsiella spp. Are the most
common. Emphysematous cholecystitis occurs in 1% of patients
with acute cholecystitis. Symptoms include RUQ pain, fever
tachycardia, and hypotension. Abdominal radiographs show fluid-
filled gallbladder, w/ gas in the gallbladder wall which can extended
into pericholecystic tissue and perihepatic ducts.

30. A 55-year-old man presents complaining of abdominal pain of
several days’ duration. He was in good health until he developed
fever and chills, malaise, and myalgias. He got scared when his
coworkers told him that his eyes were yellow. Past medical history is
unremarkable. He denies any history of alcohol abuse, intravenous
drug abuse, or blood transfusion. Vital signs include blood pressure
100/70, pulse rate 110, and temperature 38.8C (101.8F). Physical
exam reveals scleral icterus and a tender right upper quadrant.
What is the most likely diagnosis?
A) Acute cholangitis
B) Cholelithiasis
C) Hepatic metastasis
D) Pancreatic carcinoma
E) Viral hepatitis

31. A 55-year-old man presents complaining of abdominal pain of
several days’ duration. He was in good health until he developed
fever and chills, malaise, and myalgias. He got scared when his
coworkers told him that his eyes were yellow. Past medical history is
unremarkable. He denies any history of alcohol abuse, intravenous
drug abuse, or blood transfusion. Vital signs include blood pressure
100/70, pulse rate 110, and temperature 38.8C (101.8F). Physical
exam reveals scleral icterus and a tender right upper quadrant.
What is the most likely diagnosis?
A) Acute cholangitis
B) Cholelithiasis
C) Hepatic metastasis
D) Pancreatic carcinoma
E) Viral hepatitis

32. Answer:
Jaundice in the setting of a febrile illness suggests an infectious
etiology. Cholangitis is an infection of the biliary tree most commonly
due to bile duct obstruction from stones. Strictures, tumors, stenosis.
Charcot triad is present in 70% of cholangitis patients. Other
symptoms might include pruritus and hypocholic or acholic stools.
Other physical findings might include hypotension, AMS, mild
hepatomegaly and sepsis. Fluid resuscitation and borad-spectrum
antibiotics are appropriate in patients with mild cholangitis whereas
those who are more severly compromised urgently requires surgical
intervention. The most common bacteria are E coli., Klebsiella and
Enterobacter spp., enterococci and group D streptococci.

33. A 40-year-old woman presents with fever, right upper quadrant pain,
jaundice, hypotension, and altered mental status. Laboratory test
reveal elevated WBCs, bilirubin, and alkaline phosphatase levels;
lipase level is normal. Ultrasound examination demonstrates
cholelithiasis with a 10-mm common bile duct. What is the
appropriate next step in management?
A) CT Scanning
B) Emergency surgery
C) Endoscopic retrograde cholangiopancreatography
D) Hepatobiliary imino-diacetic acid scan

34. A 40-year-old woman presents with fever, right upper quadrant pain,
jaundice, hypotension, and altered mental status. Laboratory test
reveal elevated WBCs, bilirubin, and alkaline phosphatase levels;
lipase level is normal. Ultrasound examination demonstrates
cholelithiasis with a 10-mm common bile duct. What is the
appropriate next step in management?
A) CT Scanning
B) Emergency surgery
C) Endoscopic retrograde cholangiopancreatography
D) Hepatobiliary imino-diacetic acid scan

35. Answer:
Patients presenting with acute cholangitis from choledocholithiasis require biliary
decompression through ERCP. Acute cholangitis is an emergency of the biliary
tract requiring prompt recognition and treatment. Cholangitis is often caused by
obstruction of the common bile duct from stones (80%), malignancy, or stricture.
Obstruction causes an increase in the intraluminal pressures within the biliary
tract, resulting in pain and nausea. If not relieved continued obstruction leads to
reflux of gastrointestinal bacteriainto lymphatic vessels, portal vien circulation,
and subsequently systemic circulation. Seen of in less than one-third patients,
the classic presentation is the Charcot triad. The WBC count and Alk Phos and
bilirubin levels help suggest the diagnosis in less clear-cut cases. Significant
bilirubin elevations help distinguish bile duct obstrustion from simple
cholecystitis. Neither a CT scan nor a HIDA scan is helpfulin already-diagnosed
cholangitis. Initial management includes aggressive fluid resuscitation and
broad-spectrum Abx, but mortality rate approach 100% when obstruction is not
relieved. The lowest mortality rates are achieved with ERCP which is the first-
line treatment to decompress the biliary tract through removal of obstructing
stones, sphincterotomy, or stent placement. If ERCP is unsuccessful,
percutaneous transheoatic cholangiography w/ drainage should be considered.
With a mortality rate of up to 40%, emergency surgery is preformed only after
less-invasive techniques fail.

36. RECAP OF WHAT WE LEARNED
 Cholithiasis – if symptomtic tx elective out patient Sx
 Steve watches the Voice, Casey watches Real House Wives
(ie they’re both married)
 Abx for Cholangitis and Cholecystitis
 Cholithithasis and Choledochyllithasis only require emergent
surgery in our patients

37. THINGS WE DIDN’T LEARN
 Coconuts kill about 150 people each year. That's more than
sharks.
 The glue on Israeli postage is certified kosher.
 The Guinness Book of Records holds the record for being the
book most often stolen from Public Libraries.
 The word "lethologica" describes the state of not being able to
remember the word you want.
 Title 14, Section 1211 of the Code of Federal Regulations
(implemented on July 16, 1969) makes it illegal for U.S. citizens to
have any contact with extraterrestrials or their vehicles.

38. QUESTIONS?