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Cholelithiasis, Cholecystitis and Related Disorders

Cholelithiasis - the leading biliary tract disease - is the formation of stones or calculi (also called gallstones) in the gallbladder. The prognosis is usually good with treatment unless infection occurs. Then the prognosis depends on the infection's severity and its response to antibiotics.

The formation of gallstones can give rise to a number of related disorders:

  • In cholecystitis, the gallbladder becomes acutely or chronically inflamed, usually because a gallstone becomes lodged in the cystic duct, causing painful gallbladder distention. The acute form is most common during middle age; the chronic form, among elderly people. The prognosis is good with treatment.
  • In choledocholithiasis, gallstones pass out of the gallbladder and lodge in the common bile duct, causing partial or complete biliary obstruction. The prognosis is good unless infection occurs.
  • In cholangitis, the bile duct becomes infected; this disorder is commonly associated with choledocholithiasis and may follow percutaneous transhepatic cholangiography. Nonsuppurative cholangitis usually responds rapidly to antibiotic treatment. Suppurative cholangitis has a poor prognosis unless surgery to correct the obstruction and drain the infected bile is performed promptly.
  • In gallstone ileus, a gallstone obstructs the small bowel. Typically, the gallstone travels through a fistula between the gallbladder and small bowel and lodges at the ileocecal valve. This condition is most common, in elderly people. The prognosis is good with surgery.

Generally, gallbladder and duct diseases occur during middle age. Between ages 20 and 50, they're six times more common in women, but the incidence in men and women equalizes after age 50. The incidence increases with each succeeding decade.

Causes

Acute cholecystitis is almost always caused by gallstones. Other causes may include bacteria or chemical irritants. Chronic cholecystitis can occur with or without stones. But not all patients with gallstones experience cholecystitis.

Gallstones are concretions formed in the gallbladder or bile ducts. Traditionally gallstones have been classified according to their composition. This information was then used to demonstrate the cause of the stone formation. This is no longer considered valid. Generally the core of all gallstones contains a mixture of cholesterol, bilirubin, and protein.

Signs and Symptoms

Gallbladder disease may produce no symptoms (even when X-rays reveal gallstones). Acute cholelithiasis, acute cholecystitis, and choledocholithiasis produce symptoms of a classic gallbladder attack.

In a gallbladder attack, the patient typically complains of sudden onset of severe steady or aching pain in the midepigastric region or the right upper abdominal quadrant. He may describe pain that radiates to the back, between the shoulder blades or over the right shoulder blade, or just to the shoulder area. This type of pain is known as biliary colic and is the most characteristic symptom of gallbladder disease. It's often severe enough to send the patient to the emergency department.

Often, the patient reports that the attack followed eating a fatty meal or a large meal after fasting for an extended time. The attack may have occurred in the middle of the night, suddenly awakening him. He may also report nausea, vomiting, and chills; a low-grade fever may be assessed.

The patient may report a history of milder GI symptoms that preceded the acute attack. He may have experienced these symptoms for some time before seeking treatment. Such symptoms may include indigestion, vague abdominal discomfort, belching, and flatulence after eating meals or snacks high in fat.

During an acute attack, inspection confirms that the patient is in severe pain and reveals pallor, diaphoresis, and exhaustion. If he has chronic cholecystitis, inspection of the skin, sclerae, and oral mucous membranes may confirm jaundice; inspection of urine and stool specimens may reveal dark-colored urine and clay-colored stools.

Tachycardia may be noted on palpation. Light palpation of the abdomen may disclose tenderness over the gallbladder, which increases on inspiration. If a calculus-filled gallbladder without ductal obstruction is palpated, a painless, sausagelike mass can be felt.

Auscultation may reveal hypoactive bowel sounds if the patient has acute cholecystitis.

Diagnostic tests

Ultrasonography and X-rays reveal gallstones. Plain abdominal X-rays identify gallstones if they contain enough calcium to be radiopaque. X-rays are also helpful in identifying porcelain gallbladder, limy bile, and gallstone ileus. Ultrasonography of the gallbladder confirms cholelithiasis in most patients and distinguishes between obstructive and nonobstructive jaundice; calculi as small as 2 mm can be detected.

Oral cholecystography confirms the presence of gallstones, although this test is gradually being replaced by ultrasonography.

Technetium-labeled iminodiacetic acid scan of the gallbladder indicates cystic duct obstruction and acute or chronic cholecystitis if the gallbladder can't be seen.

Percutaneous transhepatic cholangiography, imaging performed under fluoroscopic control, supports the diagnosis of obstructive Jaundice and is used to visualize calculi in the ducts.

Blood studies may reveal elevated levels of serum alkaline phosphatase, lactate dehydrogenase, asparrate aminotransferase, icteric index, and total bilirubin. The white blood cell count is slightly elevated during a cholecystitis attack .

Treatment

Surgery, usually elective, remains the most common treatment for gallbladder and duct disease. Surgery is usually recommended if the patient has symptoms frequent enough to interfere with his regular routine, if he has any complications of gallstones, or if he has had a previous attack of cholecystitis.

Procedures may include cholecystectomy (laparoscopic or abdominal), cholecystectomy with operative cholangiography, choledochostomy, or exploration of the common bile duct.

If the patient's gallstones are radiolucent and consist all or in part of cholesterol, he may undergo gallstone dissolution therapy. In this procedure, the doctor uses oral chenodeoxycholic acid or ursodeoxycholic acid to partially or completely dissolve gallstones. This treatment has several limitations, including the need for prolonged treatment, the ability to dissolve only small calculi, the high incidence of adverse reactions, and the frequency of calculus reformation after treatment ends.

Other, more direct methods may be used to remove the gallstones. One of these is insertion of a percutaneous transhepatic biliary catheter under fluoroscopic guidance, which permits visualization of the calculi and their removal using a basket-shaped tool, called a Dormia basket. Another calculus-removal technique is endoscopic retrograde cholangiopancreatography (ERCP). In this procedure, the calculi are removed with a balloon or basketlike tool passed through an endoscope. Both of these techniques permit decompression of the biliary tree, allowing bile to flow.

Another technique, lithotripsy, breaks up gallstones using ultrasonic waves. It's been used successfully in some patients with radiolucent calculi. This outpatient procedure is contraindicated in patients with a pacemaker or an automatic implantable defibrillator.

If the patient is asymptomatic or has recovered from a first attack of biliary colic, noninvasive treatment may be attempted. This treatment includes a low-fat diet with replacement of the fat-soluble vitamins A, D, E, and K, and administration of bile salts to facilitate digestion and vitamin absorption.

During an acute attack, narcotics relieve pain. (Meperidine is preferred over morphine, which may constrict the sphincter and cause biliary spasm.) Antispasmodics and anticholinergics relax smooth muscles and decrease ductal tone and spasm, and antiemetics reduce nausea and vomiting. A nasogastric (NG) tube may also be inserted and connected to intermittent, low-pressure suction to relieve vomiting.

In patients with severe acute cholecystitis, I.V. fluids and I.V. antibiotic therapy are often given before surgery. Cholestyramine may be given if the patient has obstructive jaundice with severe itching from accumulation of bile salts in the skin.

Nonsuppurative cholangitis usually responds quickly to antibiotic therapy. Suppurative cholangitis requires antibiotic therapy, prompt surgical correction of the obstruction, and drainage of the infected bile.



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