GALL  BLADDER  DISEASE

 

Etiology and classification:

  1. Cholelithiasis - presence of stones in GB. Common causes are female sex, fat, OCP, DM, IBD, Hemolytic disease, pregnancy.
     
  2. Biliary Colic - transient presence (4 -5 hr.) of stone in biliary duct. VS and labs are WNL
     
  3. Cholecystitis - infection of GB associated with presence of stones. 4 F's predispose: Fat, Female, Fertile, Forty.
     
  4. Cholangitis - infection of bile duct/s associated with presence of stone.
     
  5. Acalculous Cholecystitis - infection of  GB not associated with stone. This is due to decreased blood supply as can occur secondary to massive burn, sepsis, hypotension,  atrial fibrillation, dehydration, GB vessel stasis/thrombi. For these reasons, it is commonly referred to  as "Low Flow Acalculous Cholecystitis".
     
  6. Post -cholecystectomy syndrome – May occur secondary  to biliary pigment in stump or to  stricture or retained stone in CBD. Usually presents within  a week  s/p cholecystectomy.
     

S & S:

  1. Cholelithiasis - generally symptom free. May  present with all the entities below.
     
  2. Biliary Colic - transient pain to RUQ or epigastric area. Lasts 4 -5 hr. VS are stable and labs are WNL.  Symptoms resolve completely and patient tolerates PO intake.
     
  3. Cholecystitis - post-prandial RUQ or epigastric pain, +/- pain to R shoulder, +/- N/V, Fever, +/- jaundice, Murphy's sign (pain on palpation  of  RUQ during inspiration)
     
  4. Cholangitis – Charcot's triad = fever, jaundice, RUQ pain.  Reynold's pentad adds mental status changes and hypotension.
     
  5. Acalculous Cholecystitits - pain /tenderness in  RUQ.
     
  6. Post-cholecystectomy - intermittent pain and fever with  +/-  in LFT's, amylase. Transhepatic cholangiography is diagnostic.

Note! Pt may present late and have complications such as: necrosis/gangrene, perforation,  empyema, and gallstone ileus.

DX:

  1. Few diagnostic tests are available.  We will focus on  those  that will be of use to you, as an ER health care provider.
    1. US -  quick and diagnostic for both cholelithiasis and acute cholecystitis (90 - 95%).
       
    2. CT -  also diagnostic, yet expensive. It is important to remember that CT will visualize the distal part of  CBD better than US.   However, it is less sensitive and specific for GB disease.
       
    3. HIDA - considered 100% diagnostic for  acute cholecystitis and is often used when clinical suspicion is high but US is negative.
       
    4. ERCP – assesses common and pancreatic ducts for presence of stones.
       
    5. AXR  may reveal calcified stones in 15% of cases.
       
  2. Elevation of  WBC, mild elevation in LFT, mild elevation in alk. phos. (unless stone in CBD), mild elevation in amylase, mild elevation in direct ( conjugated ) bilirubin, may all be seen with acute GB pathology.

Treatment:

  1. Due to composition of  bile in pt presenting with GB disease, LR is a solution  of choice for fluid replacement.
     
  2. Pt with symptomatic  cholelithiasis  may be referred for elective cholecystectomy. Asymptomatic cholelithiasis  (found incidentally) does not require operative intervention.
     
  3. All other entities - Cholecystitis, Cholangitis, Acalculous Cholecystitits, Post-cholecystectomy syndrome - are treated with antibiotics  with  coverage of gram negative organisms (Amp+Gent, Ticarcillin+Clavulonate=Timentin®, Piperacillin Tazobactam = Zosyn®, Amp+Sulbactam =Unasyn® ).
     
  4. If pt is PCN allergic - Cefotetan or Cefoxitin are used but these have to be added to another antibiotic that covers pseudomonas and anaerobes.  Ciprofloxasin / Metronidazole are also good alternatives.
     
  5. Surgical consultation  is mandated, and in the case of CBD stones or cholangitis, GI involvement is also warranted.

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