Updated: 1/29/2019

Cholelithiasis and Biliary Colic

Topic
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Questions
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Evidence
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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 (8)
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
Calculator

(M2.GI.25) A 42-year-old female with a history of obesity, diabetes, asthma, and hypertension presents to her primary care physician for a follow-up visit after being seen in the ED 1 week ago. She had presented to the ED with urinary urgency, dysuria, increased frequency and was diagnosed with a urinary tract infection, and ultimately discharged on appropriate antibiotic therapy. During her ED workup, an abdominal ultrasound was obtained which is demonstrated in Figure A. She currently denies a history of abdominal pain, nausea and vomiting, early satiety or any other abdominal complaints. She states that apart from her urinary tract infection, which has now successfully been resolved, she feels well. What is the appropriate management for the incidental findings observed in Figure A? Review Topic

QID: 104816
FIGURES:
1

Laparoscopic cholecystectomy

6%

(1/18)

2

Open cholecystectomy

0%

(0/18)

3

Ursodeoxycholic acid

6%

(1/18)

4

No further management at this time

83%

(15/18)

5

Endoscopic retrograde cholangiopancreatography

0%

(0/18)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.GI.41) A 42-year-old woman presents to the emergency department with severe abdominal pain. She states the pain is 9/10 in severity, is sharp in quality, located primarily on her right side, and seems to radiate to her right shoulder blade. She states that she has had similar pain in the past and it always seems to be caused by ingestion of a large meal. On exam, the patient is well appearing and her vitals are shown as: T: 36 deg C, HR: 78 bpm, BP: 130/80 mmHg, RR: 10, SaO2: 100%. A CBC, BMP, and liver function tests are ordered, and all are within normal limits. The emergency physician performs an emergency medicine bedside ultrasound (EMBU) and observes the findings shown in Figure A. What is the cause of this patient's pain? Review Topic

QID: 104832
FIGURES:
1

Viscous distension of gallbladder

65%

(13/20)

2

Inflammation of gallbladder

15%

(3/20)

3

Inflammation of common bile duct

0%

(0/20)

4

Viscous distension of cystic duct

15%

(3/20)

5

Inflammation of cystic duct

0%

(0/20)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M2.GI.4816) A 42-year-old obese female presents to the emergency room requesting a pregnancy test. On exam, blood pressure is 135/80 mmHg, heart rate is 79 bpm, respiratory rate is 18 bpm, and she is afebrile. Urine pregnancy test is found to be positive, and an abdominal ultrasound is ordered for staging. The technician inadvertently also scans the patient's right upper quadrant, and an image from this study is shown in Figure A. She denies present or history of episodic right upper quadrant pain. Which of the following is the next best step? Review Topic

QID: 107019
FIGURES:
1

HIDA scan

6%

(1/18)

2

Endoscopic retrograde cholangiopancreatography

0%

(0/18)

3

Exploratory laparoscopy

0%

(0/18)

4

Abdominal CT

0%

(0/18)

5

Discharge

89%

(16/18)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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