Updated: 11/15/2018

Cholelithiasis and Biliary Colic

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Questions
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Overview

Snapshot
  • A 49-year-old obese Hispanic female presents to a community physician late in the afternoon with progressively worsening yet constant RUQ pain that worsened after eating a fatty meal. She obtains a RUQ ultrasound scan, which reveals the presence of gallstones without pericystic fluid or wall thickening. The physician recommends ibuprofen for pain relief, increased fluid intake, minimal fatty food intake, and follow-up in two days for reevaluation of labs, including the patients bilirubin and amylase levels.
Introduction
  • Risk factors for cholesterol stones: Four F's
    • Fat (obesity)
    • Female (estrogen source - OCP)
    • Forty
    • Fertile (multiparity)
    • impaired gallbladder emptying: starvation, diabetes (paresis), TPN  
    • rapid weight loss (due to rapid cholesterol mobilization and biliary stasis)
    • terminal ileal resection or disease (e.g., Crohn's)
    • Native American heritage (especially Pima Indians)
  • Risk factors for pigment stones (calcium-based)
    • cirrhosis
    • biliary stasis (strictures, dilation, biliary infection)
    • chronic hemolysis
Presentation
  • Symptoms
    • gallstones are common and most are asymptomatic (80%)
    • biliary colic is transient impaction of gallstone in cystic duct without evidence of infection
      • steady, severe dull pain in epigastrium or RUQ for minutes to hours
      • crescendo-decrescendo pattern
      • possible presence of chest pain
      • possible radiation to right scapula or shoulder
    • no systemic signs or peritoneal signs
    • frequently after fatty meal (secondary to cholecystokinin (CCK) release) or at night 
    • symptoms similar to colic can also be caused by spincter of Oddi dysfunction, which can be diagnosed with spincter manometry and treated with spincerterotomy via ERCP
Evaluation
  • Imaging
    • first-line: RUQ ultrasound  
    • ERCP (endoscopic retrograde cholangiopancreatography)
      • diagnostic: visualizes upper GI tract, ampullary region, biliary and pancreatic ducts
      • therapeutic: treats common bile duct stones in periampullary region
    • MRCP (magnetic resonance cholangiopancreatography)
      • non-invasive compared to ERCP, but not therapeutic
    • radiograph only valuable if positive because 15-20% of gallstones are radiopaque
  • Labs
    • most important labs for biliary pain
      • total and direct bilirubin levels: for evidence of obstruction
      • amylase: for evidence of gallstone pancreatitis
    • CBC, electrolytes, LFTs
Treatment
  • Asymptomatic patients do not require cholecystectomy  
  • Pain control, rehydration during colic episode
  • Sphincter of Oddi dysfunction presents similar to acute cholecystitis
    • ERCP with sphincterotomy 
  • Elective laparoscopic cholecystectomy
    • no evidence of benefit for delaying surgery
    • patients at risk for cancer should have cholecystectomy
      • Native Americans
      • patients with imaging suggestive of porcelain gallbladder (gallbladder cancer)
    • cholecystectomy for patients with recurrent biliary colic or evidence of pancreatitis
 

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Questions (11)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.71) A 46-year-old female presents with severe postprandial right upper quadrant pain. She has had similar symptoms off and on for the last several years with the pain remitting after approximately a day. She undergoes an abdominal CT scan which is shown in Figure A. Based on the imaging findings, this patient is at increased risk for which of the following conditions? Review Topic

QID: 104862
FIGURES:
1

Pancreatic carcinoma

0%

(0/9)

2

Gallbladder carcinoma

89%

(8/9)

3

Hepatocellular carcinoma

11%

(1/9)

4

Aneurysm rupture

0%

(0/9)

5

Echinococcal cyst rupture

0%

(0/9)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M2.GI.62) A 30-year-old G3P3 female presents with a history of multiple episodes of right upper quadrant (RUQ) pain following fatty or heavy meals for the past year. The pain occurs in waves and resolves on its own. It is deep and achey in quality. She has a history of hypertension. Her past medical history is significant for prior cholecystectomy and splenectomy, as well as two episodes of pancreatitis for which no cause was identified. Physical exam reveals an obese female in no distress, and tenderness to deep palpation in the RUQ. LFTs are elevated to twice the upper limit of normal. MRCP shows a dilated common bile duct and no other abnormalities. What course of action is most likely to lead to the correct diagnosis? Review Topic

QID: 104853
1

Blood test for anti-mitochondrial antibody

25%

(2/8)

2

Spincter of Oddi manometry

75%

(6/8)

3

Upper GI series

0%

(0/8)

4

Hydrogen breath test

0%

(0/8)

5

Capsule endoscopy

0%

(0/8)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M2.GI.10) For which of the following patients is an abdominal ultrasound the most appropriate first diagnostic test? Review Topic

QID: 104801
1

69-year-old female smoker with 10 pound weight loss and change in sputum

0%

(0/68)

2

64-year-old male with known prostate cancer presenting with lower extremity weakness and loss of bladder control

1%

(1/68)

3

58-year-old male with Marfan syndrome presenting with acute onset chest pain radiating to the back

6%

(4/68)

4

28-year-old female with Crohn's disease presenting with 5 hours of abdominal pain, constipation, and nausea

0%

(0/68)

5

48-year-old mother of 3 with a history of right upper quadrant pain following fatty meals

91%

(62/68)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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