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Mujer de 42 con hipocondralgia derecha esp
- 1. Mujer de 42 con hipocondralgia derecha
- 2. Mujer de 42 con hipocondralgia derecha • Mujer 45 años • Obesidad troncular IMC 35 • Dislipemia y alteración metabolismo glucídico • Hipertensión arterial • No fuma • Madre diabética tipo 2 • Dispepsia grasa • Digestiones pesadas • Acude por dolor HD de 2 horas de duración • Sensación nauseosa • Lo ha tenido otras veces Programamos una ecografía abdominal
- 4. Epidemiología de la enfermedad biliar • Según una encuesta del National Health and Nutrition Examination Survey (NHANES III), la prevalencia de litiasis biliar es del 5.5% en varones y del 8.6% en mujeres • Varía con la edad y la raza • Son más comunes en la DM2 y mayor riesgo de colecistitis gangrenosa • Más del 30% de los obesos sometidos a CB Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 5. Fisiopatología de la enfermedad biliar • La litiasis biliar se produce tras la presencia de barro biliar, una mezcla viscosa de glicoproteínas, depósitos de calcio, y los cristales de colesterol en la vesícula biliar o los conductos biliares • La mayoría de cálculos provienen de bilis saturada con colesterol. • Alteración de la movilidad de la VB • En ocasiones se deben a un exceso de bilirubina Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 7. Factores de riesgo • 4F (female, fertile, fatty, forty) • Los estrogenos incrementan el colesterol y su saturación en la bilis y disminuyen la movilidad de la vesicula b. • Dieta alta en grasas y carbohidratos. Sedentarismo, DM2 y la dislipemia. • Grupos étnicos Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117:632. Schmidt M, Hausken T, Glambek I, et al. A 24-year controlled follow-up of patients with silent gallstones showed no long-term risk of symptoms or adverse events leading to cholecystectomy. Scand J Gastroenterol 2011; 46:949. Friedman GD, Raviola CA, Fireman B. Prognosis of gallstones with mild or no symptoms: 25 years of follow-up in a health maintenance organization. J Clin Epidemiol 1989; 42:127.
- 9. Presentación • Asintomática • Menos común como cólico biliar, dolor abdominal, nauseas, o ictericia. Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 10. Presentación • Colico biliar.- dolor agudo –no siempre cólico- postprandial, epigastrio o en HD que dura de pocos minutos a varias horas. • Si existe colecistitis: SIGNO de MURPHY (dolor agudo que para la respiración al palpar la vesicula biliar) Y/O ICTERICIA • Signos inespecíficos como indigestión, intolerancia las grasas, fritos, eructos o flatulencia Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117:632. Schmidt M, Hausken T, Glambek I, et al. A 24-year controlled follow-up of patients with silent gallstones showed no long-term risk of symptoms or adverse events leading to cholecystectomy. Scand J Gastroenterol 2011; 46:949. Friedman GD, Raviola CA, Fireman B. Prognosis of gallstones with mild or no symptoms: 25 years of follow-up in a health maintenance organization. J Clin Epidemiol 1989; 42:127.
- 11. Diagnóstico • Laboratorio, pruebas hepáticas, amilasas…con la que discriminar la litiasis de sus complicaciones. • Ecografía abdominal • Colescistografía • Colangiopancreatografía (ERCP) Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 12. Ecografía (1) • Los signos positivos son cálculos, engrosamiento de la pared de la vesícula biliar, fluido pericolecistico, signo de Murphy ecográfico • La ecografía en ayunas dectecta más el 90% de los casos de cálculos biliares. • Los cálculos en el cístico pueden no detectase en un 50% Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 14. Ecografía (2) La práctica de ecografía rutinaria en dolores abdominales, o pélvicos o por alteración de la función hepática permite detectar la identificación de cálculos asintomáticos. La mayoría de ellos sus síntomas no se deben a los cálculos Si bien es cierto, que aproximadamente el 20% tendrán síntomas en los 15 años siguientes. Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012. Barbara L, Sama C, Morselli Labate AM, et al. A population study on the prevalence of gallstone disease: the Sirmione Study. Hepatology 1987; 7
- 15. Colecistografía • Trazador radioactivo con el que visualizar los conductos (hepatobiliary iminodiacetic acid (HIDA) scan. • Se usa para evaluar la función de la vesícula biliar • Para diagnosticar la colecistitis aguda. S 97% y E 94% • No es útil en cálculos y colecistitis crónica • Puede producir falsos positivos en un 30-40% crónica Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 16. Colangiopancreotografía retrógrada endoscópica (ERCP) En coledocolitiasis ERCP sirven no solo para identificar los cálculos en vias biliares si no para extraerlos ERCP tiene como complicación la pancreatitis Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 17. Ecografía endoscópica • Identifica cálculos en el colédoco pero no los elimina • Es menos preciso que otros métodos de imagen pero detecta el 75% de los cálculos en estas localizaciones Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 18. Colangiopancreatografía por RMN • La MRCP se utiliza en coledocolitiasis y otras anomalias del árbol biliar. • El MRCP tiene una sensibilidad del 98%. Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 UPTODATE. 15-09-2013
- 19. Tratamiento • Pacientes asintomáticos no precisan tratamiento • El pacientes sintomáticos: colecistectomía laparoscópica (CL) • La CL genera menores costes, días de hospitalización, y recuperación de paciente Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 20. Colecistectomia • Su utilización profiláctica no está indicada en pacientes asintomáticos • Solo cuando existe riesgo de carcinoma de vías biliares o de complicaciones Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012. Friedman GD, Raviola CA, Fireman B. Prognosis of gallstones with mild or no symptoms: 25 years of follow-up in a health maintenance organization. J Clin Epidemiol 1989; 42:127. Diehl AK. Gallstone size and the risk of gallbladder cancer. JAMA 1983; 250:2323.
- 21. Terapia no intervencionista • Disolución de los cálculos mediante ácidos biliares • Ácido quenodeoxicolico (quenobilian) 10-15 mg/Kg/d y ácido ursodeoxicolico (ursochol 150 mg) 8-10 mg/kg/d • Son efectivos en pequeños cálculos (0,5–1 cm) aunque pueden tardar 24 meses en disolverlos • Disolución mediante litotricia con ondas de choque Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 22. Cambio de los estilos de vida y nutrición • La pérdida de peso ayuda a evitar la formación de cálculos • Los ácidos grasos poli y monoinsaturados, la fibra dietética y la cafeína pueden ayudar. • Aceite de pescado • Consumo moderado de alcohol Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 23. La enfermedad biliar (1) • Normalmente no se diagnostica pues no da síntomas. • Los síntomas van desde el “cólico biliar” a sintomatología inespecífica tipo dispepsia. • Aunque normalmente no es la causa de la dispepsia. Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 24. La enfermedad biliar (2) • Habitualmente se diagnostican por pruebas de imagen • El laboratorio, pruebas hepáticas, amilasa, lipasas ayudan a distinguir las complicaciones Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 25. La enfermedad biliar (3) • Aunque la litiasis biliar es asintomática puede progresar con síntomas.. • La manifestación clínica de la complicación es la colecistitis • Menos común es la pancreatitis, perforación biliar, obstrucción, degeneración neoplásica etc… Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
- 26. Ideas clave: Es una enfermedad frecuente Habitualmente asintomática Si la litiasis biliar es asintomátic no precisa operación Si los cálculos son menores de 1 cm se puede probar con métodos no intervencionistas Los estilos de vida son preventivos de la enfermedad Simore Afamefuna, PharmD Candidate, Shari N. Allen, PharmD, Gallbladder Disease. Pathophysiology, Diagnosis, and Treatment. Medscape 2013 http://www.medscape.com/viewarticle/781782 Nezam H Afdhal,Sanjiv Chopra,Deputy Anne C Travis UPTODATE. his topic last updated: oct 11, 2012.
Hinweis der Redaktion
- The prevalence of gallstones and gallstone related disease in the United States was estimated based upon data from the third National Health and Nutrition Examination Survey (NHANES III), in which gallbladder ultrasonography was performed in a representative sample of more than 14,000 people [5]. The overall prevalence of gallstones and gallbladder disease (ie, either the presence of gallstones or ultrasonographic evidence of cholecystectomy) was 5.5 and 7.9 percent respectively in men, and 8.6 and 16.6 percent, respectively in women. As expected, the prevalence varied depending upon age and ethnicity. The prevalence of gallstones and gallbladder disease was highest in men and women between the ages of 60 to 74 (table 2), and among Mexican Americans compared with non-Hispanic whites and blacks. Gastric bypass surgery — Morbidly obese patients who have undergone gastric bypass surgery, a form of bariatric surgery, have a high incidence of developing gallstones (greater than 30 percent) Diabetes mellitus — Gallstones are more common in diabetic patients. (See "Epidemiology of and risk factors for gallstones".) Predominantly anecdotal evidence suggests that diabetic patients are at increased risk for the development of severe gangrenous cholecystitis [11].[15,16]. An incidental cholecystectomy is recommended by some at the time of surgery, though the issue is controversial.
- The formation of gallstones is often preceded by the presence of biliary sludge, a viscous mixture of glycoproteins, calcium deposits, and cholesterol crystals in the gallbladder or biliary ducts.[5] In the U.S., most gallstones consist largely of bile supersaturated with cholesterol.[1,2] This hypersaturation, which results from the cholesterol concentration being greater than its solubility percentage, is caused primarily by hypersecretion of cholesterol due to altered hepatic cholesterol metabolism.[1,3] A distorted balance between pronucleating (crystallization-promoting) and antinucleating (crystallization-inhibiting) proteins in the bile also can accelerate crystallization of cholesterol in the bile.[1–3,5] Mucin, a glycoprotein mixture secreted by biliary epithelial cells, has been documented as a pronucleating protein. It is the decreased degradation of mucin by lysosomal enzymes that is believed to promote the formation of cholesterol crystals. Loss of gallbladder muscular-wall motility and excessive sphincteric contraction also are involved in gallstone formation.[1] This hypomotility leads to prolonged bile stasis (delayed gallbladder emptying), along with decreased reservoir function.[3,5] The lack of bile flow causes an accumulation of bile and an increased predisposition for stone formation. Ineffective filling and a higher proportion of hepatic bile diverted from the gallbladder to the small bile duct can occur as a result of hypomotility.[1,5] Occasionally, gallstones are composed of bilirubin, a chemical that is produced as a result of the standard breakdown of RBCs. Infection of the biliary tract and increased enterohepatic cycling of bilirubin are the suggested causes of bilirubin stone formation. Bilirubin stones, often referred to as pigment stones, are seen primarily in patients with infections of the biliary tract or chronic hemolytic diseases (or damaged RBCs).[1,3,6] Pigment stones are more frequent in Asia and Africa.[3,6] The pathogenesis of cholecystitis most commonly involves the impaction of gallstones in the bladder neck, Hartmann's pouch, or the cystic duct; gallstones are not always present in cholecystitis, however.[5] Pressure on the gallbladder increases, the organ becomes enlarged, the walls thicken, the blood supply decreases, and an exudate may form.[2,5] Cholecystitis can be either acute or chronic, with repeated episodes of acute inflammation potentially leading to chronic cholecystitis. The gallbladder can become infected by various microorganisms, including those that are gas forming. An inflamed gallbladder can undergo necrosis and gangrene and, if left untreated, may progress to symptomatic sepsis.[1,2,5] Failure to properly treat cholecystitis may result in perforation of the gallbladder, a rare but life-threatening phenomenon.[2,5,7] Cholecystitis also can lead to gallstone pancreatitis if stones dislodge down to the sphincter of Oddi and are not cleared, thus blocking the pancreatic duct.[1]
- Genetic and environmental factors contribute to gallbladder disease. Female gender, previous pregnancies, and family history of gallstone disease are highly correlated with cholelithiasis.[1,3] Approximately 60% of patients with acute cholecystitis are women; however, the disease tends to be more severe in men.[2] Estrogen increases cholesterol and its saturation in bile and promotes gallbladder hypomotility.[1] Diminished gallbladder motility is commonly seen during pregnancy.[9] Other risk factors include a high dietary intake of fats and carbohydrates, a sedentary lifestyle, type 2 diabetes mellitus, and dyslipidemia (increased triglycerides and low HDL).[3,9] A diet high in fats and carbohydrates predisposes a patient to obesity, which increases cholesterol synthesis, biliary secretion of cholesterol, and cholesterol hypersaturation. However, a direct correlation between high dietary intake of fats and cholelithiasis risk has not been established because previous studies have yielded controversial results.[9] Acute cholecystitis develops more frequently in symptomatic cholelithiasis patients with type 2 diabetes mellitus than in symptomatic patients without it.[2] These patients also are more likely to have complications. American Indians have the highest prevalence of cholelithiasis, with the disease reaching epidemic proportions in this population. Gallstone disease is also prevalent in Chilean and Mexican Hispanics.[3,9] In addition to ethnicity, age plays a role in gallstone disease. Patients who develop complicated symptomatic cholelithiasis tend to be older, and the typical patient with gallstones is in her 40s.[1,2]
- Clinical Presentation Gallstones are generally asymptomatic. In the uncommon event that a patient develops symptomatic cholelithiasis, presentation can range from mild nausea or abdominal discomfort to biliary colic and jaundice.[1,5,10] Biliary colic, usually sharp in nature, is postprandial epigastric or right-quadrant pain that lasts for several minutes to several hours. The pain often radiates to the back or the right shoulder, and in more intense cases it may be accompanied by nausea and vomiting. Upper-right-quadrant tenderness and palpable infiltrate in the region of the gallbladder are revealed upon physical examination.[5,10] Cholecystitis presents in the same manner; however, the obstruction of the cystic duct is persistent (rather than transient), and fever is common.[10] A patient with cholecystitis also may exhibit Murphy's sign (discomfort so severe that the patient stops inspiring during palpation of the gallbladder) or jaundice. Jaundice, a yellow discoloration of the skin and the sclera of the eyes, occurs when the common bile duct is obstructed because of an impacted stone in Hartmann's pouch (Mirizzi's syndrome). Other nonspecific symptoms, such as indigestion, intolerance to fatty or fried foods, belching, and flatulence, may also be present.[1,5,10]
- Clinical Presentation Gallstones are generally asymptomatic. In the uncommon event that a patient develops symptomatic cholelithiasis, presentation can range from mild nausea or abdominal discomfort to biliary colic and jaundice.[1,5,10] Biliary colic, usually sharp in nature, is postprandial epigastric or right-quadrant pain that lasts for several minutes to several hours. The pain often radiates to the back or the right shoulder, and in more intense cases it may be accompanied by nausea and vomiting. Upper-right-quadrant tenderness and palpable infiltrate in the region of the gallbladder are revealed upon physical examination.[5,10] Cholecystitis presents in the same manner; however, the obstruction of the cystic duct is persistent (rather than transient), and fever is common.[10] A patient with cholecystitis also may exhibit Murphy's sign (discomfort so severe that the patient stops inspiring during palpation of the gallbladder) or jaundice. Jaundice, a yellow discoloration of the skin and the sclera of the eyes, occurs when the common bile duct is obstructed because of an impacted stone in Hartmann's pouch (Mirizzi's syndrome). Other nonspecific symptoms, such as indigestion, intolerance to fatty or fried foods, belching, and flatulence, may also be present.[1,5,10] The cardinal symptom of gallstones is biliary colic. Biliary colic is a moderately severe crescendo type pain in the right upper quadrant radiating to the back and right shoulder, which may be accompanied by nausea. Despite its name, the pain is usually steady and not colicky. Pain may be brought on after ingestion of fatty foods. Gallstones are sometimes implicated as the source of symptoms in patients with dyspepsia. However, such an association should be made cautiously, since gallstones may silently coexist in patients with dyspepsia, and other causes of dyspepsia are more common. (See 'Natural history of asymptomatic gallstones' above.)
- Diagnosis Current techniques for diagnosing gallbladder disease are less invasive and allow patients to recover more quickly than was the case with earlier diagnostic procedures.[10] Although the incidence of cholelithiasis is quite high in the U.S., few patients present with symptoms.[4] This can complicate and prolong the diagnosis. CBC, liver-function testing, and serum amylase and lipase should be included in the laboratory tests to help discriminate between the various types of gallbladder disease and/or identify complications caused by gallbladder disease (Table 2).[5,10] The diagnosis of cholelithiasis, cholecystitis, and other gallbladder diseases can be confirmed via a number of different imaging techniques. Ultrasonography and cholescintigraphy are the imaging studies most commonly used to diagnose cholelithiasis and cholecystitis.[10] Positive findings upon ultrasonography include stones, thickening of the gallbladder wall, pericholecystic fluid, and Murphy's sign (i.e., pain) upon contact with the ultrasonographic probe.[10] Ultrasonography performed in the fasting state reveals the correct diagnosis in more than 90% of cases, but bile-duct stones may be missed in 50% of cases.[3] Cholescintigraphy, also called hepatobiliary iminodiacetic acid (HIDA) scan, is used to assess the function of the gallbladder and to diagnose acute cholecystitis. HIDA scans are not helpful in identifying cholelithiasis or chronic cholecystitis.[11] In ambulatory patients, cholescintigraphy provides a correct diagnosis more than 95% of the time. However, cholescintigraphy may produce false-positive results in 30% to 40% of hospitalized patients, particularly those receiving parenteral nutrition. Ultrasonography is the preferred diagnostic method in these patients.[10] Cholescintigraphy results are considered abnormal when the radioactive tracer or dye does not visualize the gallbladder, moves slowly through the bile ducts, or is detected outside the biliary system.[12] If choledocholithiasis is suspected, endoscopic retrograde cholangiopancreatography (ERCP) may be beneficial. ERCP is used to identify common bile-duct stones and also may be used to remove them. ERCP is associated with complications such as pancreatitis. Noninvasive techniques, such as endoscopic ultrasonography, may be used to detect cholelithiasis, but not to remove the stones.[4,11] CT may be used, but it is considered less accurate than other imaging methods, as it detects approximately 75% of gallstones.[4,10] Magnetic resonance cholangiopancreatography (MRCP) is an imaging method used to detect choledocholithiasis and other abnormalities of the biliary tract. MRCP has a sensitivity of approximately 98%.[4,11]
- Positive findings upon ultrasonography include stones, thickening of the gallbladder wall, pericholecystic fluid, and Murphy's sign (i.e., pain) upon contact with the ultrasonographic probe.[10] Ultrasonography performed in the fasting state reveals the correct diagnosis in more than 90% of cases, but bile-duct stones may be missed in 50% of cases. The routine use of ultrasonography for the evaluation of abdominal pain, pelvic disease, and abnormal liver function tests has led to the identification of incidental gallstones in many patients]. The majority of these patients have no symptoms attributable to the gallstones; however, approximately 20 percent will become symptomatic during up to 15 years of follow-up
- Positive findings upon ultrasonography include stones, thickening of the gallbladder wall, pericholecystic fluid, and Murphy's sign (i.e., pain) upon contact with the ultrasonographic probe.[10] Ultrasonography performed in the fasting state reveals the correct diagnosis in more than 90% of cases, but bile-duct stones may be missed in 50% of cases. The routine use of ultrasonography for the evaluation of abdominal pain, pelvic disease, and abnormal liver function tests has led to the identification of incidental gallstones in many patients]. The majority of these patients have no symptoms attributable to the gallstones; however, approximately 20 percent will become symptomatic during up to 15 years of follow-up
- Cholescintigraphy, also called hepatobiliary iminodiacetic acid (HIDA) scan, is used to assess the function of the gallbladder and to diagnose acute cholecystitis. HIDA scans are not helpful in identifying cholelithiasis or chronic cholecystitis.[11] In ambulatory patients, cholescintigraphy provides a correct diagnosis more than 95% of the time. However, cholescintigraphy may produce false-positive results in 30% to 40% of hospitalized patients, particularly those receiving parenteral nutrition. Ultrasonography is the preferred diagnostic method in these patients.[10] Cholescintigraphy results are considered abnormal when the radioactive tracer or dye does not visualize the gallbladder, moves slowly through the bile ducts, or is detected outside the biliary system.[12] A cholescintigraphy scan, also known as: Hepatobiliary Iminodiacetic Acid HIDA, Paraisopropyl Iminodiacetic Acid PIPIDA, or Diisopropyl Iminodiacetic Acid DISIDA scan is a nuclear imaging procedure to evaluate the health and function of the gallbladder. A radioactive tracer, usually a 99 Tc-iminodiacetic acid chelate complex, is injected through any accessible vein, then allowed to circulate to the liver, where it is excreted into the biliary system and stored by the gallbladder and biliary system.[1] In the absence of disease, the gallbladder is visualized within 1 hour of the injection of the radioactive tracer. If the gallbladder is not visualized within 4 hours after the injection, this indicates either cholecystitis or cystic duct obstruction. This investigation is usually conducted after an ultrasound examination of the abdominal right upper quadrant for pain. If the non-invasive ultrasound examination fails to demonstrate gall stones (or other obstruction to the gall bladder or biliary tree) in an attempt to establish a cause of right upper quadrant pain, this cholescintigraphy scan can be performed as a more sensitive and specific test. Cholescintigraphy scans are not generally done first line due to their increased cost and invasiveness. Cholescintigraphy for acute cholecystitis has sensitivity of 97%, specificity of 94%.[2] Several investigators have found the senstivity being consistently higher than 90% though specificity has varied from 73%- 99%, yet compared to ultrasonography, cholescintigraphy has proven to be superior.[3] The scan is also important to differentiate between Neonatal Hepatitis and Biliary atresia, because an early surgical intervention in form of Kasai portoenterostomy or Hepatoportoenterostomy can save the life of the baby as the chance of a successful operation after 3 months seriously decreases.[4] 99 Tc Hepato Iminodiacetic Acid (HIDA/Lidofenin) is rarely used currently, as 99 Tc Paraisopropyl Iminodiacetic Acid (PIPIDA), 99 Tc Diisopropylacetanilido Iminodiacetic Acid (DISIDA/Disofenin) or 99 Tc bromo-2, 4,6-trimethylacetanilido Iminodiaceticacid (BrIDA/Mebrofenin) have replaced it[5][6] , but the term HIDA remains.
- If choledocholithiasis is suspected, endoscopic retrograde cholangiopancreatography (ERCP) may be beneficial. ERCP is used to identify common bile-duct stones and also may be used to remove them. ERCP is associated with complications such as pancreatitis. Noninvasive techniques, such as endoscopic ultrasonography, may be used to detect cholelithiasis, but not to remove the stones.[4,11] CT may be used, but it is considered less accurate than other imaging methods, as it detects approximately 75% of gallstones.[4,10] Magnetic resonance cholangiopancreatography (MRCP) is an imaging method used to detect choledocholithiasis and other abnormalities of the biliary tract. MRCP has a sensitivity of approximately 98%.[4,11]
- Noninvasive techniques, such as endoscopic ultrasonography, may be used to detect cholelithiasis, but not to remove the stones.[4,11] CT may be used, but it is considered less accurate than other imaging methods, as it detects approximately 75% of gallstones.[4,10]
- Magnetic resonance cholangiopancreatography (MRCP) is an imaging method used to detect choledocholithiasis and other abnormalities of the biliary tract. MRCP has a sensitivity of approximately 98%.[
- Patients experiencing asymptomatic cholelithiasis do not require treatment.[5] The treatment of choice for symptomatic cholelithiasis currently is laparoscopic cholecystectomy, whereas previously it was open cholecystectomy.[3,10] Laparoscopic cholecystectomy is associated with a shorter hospital stay and a faster recovery period than open cholecystectomy is. Absolute contraindications to this procedure include the inability to withstand general anesthesia, an intractable bleeding disorder, and end-stage liver disease.[3,5] In patients who are unable or unwilling to undergo surgery, endoscopic decompression by internal gallbladder stent can help prevent complications from developing and can serve as palliative long-term treatment.[5] Nonoperative therapy, which includes dissolution of gallstones using oral bile acids and shock wave lithotripsy, may be another option in such patients. However, nonoperative therapy is time consuming and is associated with high cost, low effectiveness, and a high recurrence rate.[5,13]
- Thus, prophylactic cholecystectomy is not indicated in most patients with asymptomatic gallstones. Possible exceptions include patients who are at increased risk for gallbladder carcinoma or gallstone complications, in whom prophylactic cholecystectomy or incidental cholecystectomy at the time of another abdominal operation can be considered
- Nonoperative therapy, which includes dissolution of gallstones using oral bile acids and shock wave lithotripsy, may be another option in such patients. However, nonoperative therapy is time consuming and is associated with high cost, low effectiveness, and a high recurrence rate.[5,13] Oral bile acids used for the dissolution of gallstones include chenodeoxycholic acid (chenodiol) and ursodeoxycholic acid (ursodiol) (Table 3).[5,14] Oral bile acids are most effective for small gallstones (0.5–1 cm) and may take up to 24 months to clear the stones. Ursodiol is the most commonly used oral bile acid, secondary to its safer side-effect profile compared with chenodiol. Chenodiol is associated with dose-dependent diarrhea as well as with hepatotoxicity, hypercholesterolemia, and leukopenia, all of which limit its use.[14]
- Nutrition and lifestyle changes may be beneficial for the prevention and treatment of cholelithiasis. Because obesity is associated with an increased risk of cholelithiasis, weight loss may help prevent gallstone formation.[15] However, excessively rapid weight loss may promote gallstone formation. Dietary factors that may help prevent gallstone formation include polyunsaturated fat, monounsaturated fat, fiber, and caffeine.[15] Fish oil and moderate alcohol consumption have been shown to lower triglycerides, lessen bile cholesterol saturation, and increase HDL.[3,9]
- Gallbladder disease, particularly cholelithiasis (gallstones), affects more than 20 million Americans each year. Patients often go undiagnosed because cholelithiasis often does not present with symptoms. Symptoms range from nausea or abdominal discomfort to biliary colic and jaundice. Gallbladder diseases are diagnosed most accurately via imaging techniques. However, laboratory values such as CBC, liver-function testing, and serum amylase and lipase should be included to help distinguish the type of gallbladder disease and/or identify associated complications. The most effective treatment for patients with gallbladder disease is surgery. Gallbladder disease is influenced by diet, exercise, and nutrition, and patients should be encouraged to incorporate these healthy habits into their lifestyle in order to reduce their risk of gallbladder disorders. Gallstones are sometimes implicated as the source of symptoms in patients with dyspepsia. However, such an association should be made cautiously since gallstones may silently coexist in patients with dyspepsia, and other causes of dyspepsia are more common.
- The most common form of gallbladder disease is cholelithiasis (gallstones).[1] Cholelithiasis affects more than 20 million Americans annually, resulting in a direct cost of more than $6.3 billion.[2] Gallstones generally are asymptomatic and typically are discovered during a surgical procedure for an unrelated condition or during autopsy.[1,2] In the United States, cholelithiasis is the most common inpatient diagnosis among gastrointestinal and liver diseases.[3,4] Although gallstones are usually asymptomatic, some patients progress to symptomatic disease. The primary clinical manifestation and complication of cholelithiasis is cholecystitis (inflammation of the gallbladder).[1,2] Less commonly, patients with severe cases may develop gallstone pancreatitis, gallbladder perforation, or other gallbladder diseases