Cholelithiasis and Biliary Colic - Gastrointestinal

Snapshot
A 46-year-old woman presents to her primary care physician for recurrent right upper quadrant pain. She reports 30-minute episodes of abdominal pain after eating meals, especially with fast food meals. She has not had any fevers or chills, and her episodes always resolve. Her past medical history includes hyperlipidemia, morbid obesity, and polycystic ovarian syndrome, for which she takes oral contraceptives. Her physician orders a right upper quadrant ultrasound, which shows gallstones without any wall thickening. Her physician recommends conservative measures for now, including dietary changes.
Introduction
Clinical definition cholelithiasis stones in gallbladder are cholesterol or pigment stones biliary colic right upper quadrant abdominal pain following meals, usually associated with nausea and vomiting that self-resolves occurs particularly after fatty or heavy meals (secondary to cholecystokinin (CCK) release) or at night Epidemiology demographics female > male adults risk factors cholesterol stones (most common) F’s Fat Female Forty Fertile impaired gallbladder emptying total parenteral nutrition starvation diabetes biliary stasis rapid weight loss Native American heritage pigment stones cirrhosis biliary stasis chronic hemolysis Pathogenesis cholesterol saturation can cause impaired gallbladder motility gallstones can lead to mechanical obstruction of biliary tract and cause bacterial overgrowth Associated conditions acute cholecystitis ascending cholangitis acute pancreatitis gallstone ileus
Presentation
Symptoms cholelithiasis may be asymptomatic biliary colic colicky pain in right upper quadrant may radiate to the right shoulder triggered by fatty or heavy foods episodes self-resolve
Studies
Diagnostic testing diagnostic approach gallstones may be found incidentally on abdominal imaging imaging right upper quadrant ultrasound findings gallstones magnetic resonance cholangiopancreatography (MRCP) indication ultrasound results are equivocal endoscopic retrograde cholangiopancreatography (ERCP) indication both diagnostic and therapeutic if intervention is indicated studies alkaline phosphatase and bilirubin may be elevated but only mildly amylase to assess for gallstone pancreatitis Diagnostic criteria gallstones on imaging
Differential
Peptic ulcer disease distinguishing factors epigastric gnawing pain that may improve with meals ultrasound will show no signs of biliary disease Sphincter of Oddi dysfunction distinguishing factors presents similarly to biliary colic diagnosed with manometry treated with sphincterotomy via ERCP
Treatment
Management approach incidental asymptomatic gallstones do not require any treatment antibiotics are not needed for simple cholelithiasis and biliary colic First-line supportive care analgesia NSAIDs diet avoid fatty foods that trigger biliary colic rehydration elective cholecystectomy indications symptomatic cholelithiasis patients at risk for cholangiocarcinoma Native American heritage porcelain gallbladder gallstone pancreatitis Second-line ursodeoxycholic acid indication patients unwilling or contraindicated to undergo cholecystectomy can be used as prophylaxis mechanism dissolves gallstones
Complications
Secondary infections