Ana de Luca
Gallblader and Gallstones: risk factors → 4F’s → fat, female, fertile and fory.
- Progesterone inhibits galllblader motility.
pancreas - Pigment stones are composed of bilirrubin and are secondary
to RBC turnover → ex: patient with sicke cell anemia and RUQ
Anatomy pain may have cholelithiasis.
- Asymptomatic found on ultrasound require no treatment.
The gallbladder is a small, pouch-like organ that stores the bile
- Symptomatic cholelithiasis → elective surgery.
produced by the liver.
- Cholecystitis → atb. and urgent attention.
- Choledocholithiasis is the stone impactation within the
After a fatty meal, the gallbladder contracts and releases bile to
common Bille duct and can lead to cholangitis, which is the
help break down fats in the diet.
ascending infection of the biliary tree → endoscopic removal
via ERCP + IV antibiotics.
Bile is made up mostly of water, bile salts, bilirubin, fats and
as cholesterol.
Symptomatic Cholelithiasis (Biliary Colic)
Now, the most common gallbladder diseases have to do with an
Gallstones, when symptomatic, cause colicky RUQ pain after
imbalance in bile uid composition, which leads to the formation
fatty meals when the gallbladder contracts against a stone
of stones either in the gallbladder or somewhere along the biliary
lodged in the cystic duct under the stimulation of CCK.
tree.
Murphy’s sign will not be present.
2 types of stones:
1. Cholesterol stones → associated with obesity, Crohn
disease, advanced age, estrogen therapy, multiparity, rapid
weight loss, medications (eg, brates).
2. Pigment stones → associated with Crohn disease, chronic
hemolysis, alcoholic cirrhosis, advanced age, biliary
infections, total parenteral nutrition (TPN).
For most asymptomatic individuals, the usual plan is watchful
waiting. However, for symptomatic individuals or those at high
risk for developing symptoms, treatment is necessary.
A gallstone in the gallbladder is called cholelithiasis, and
- High risk individuals include those with hemolytic
a gallstone in the common bile duct is
disorders like sickle cell disease, morbidly obese individuals
called choledocolithiasis, and both are associated with mild
who undergo gastric bypass or individuals who have risk
in ammation. But, if the gallstones block the normal bile ow this
factors for developing gallbladder cancer,
can cause severe in ammation in the biliary tree.
like gallstones bigger than 3 centimeters, a
calci ed gallbladder wall, also called a porcelain
When there’s a lot of in ammation, the gallbladder and common
gallbladder, and gallbladder adenomas.
bile duct tissue becomes extremely susceptible to infection. An
infection of an obstructed gallbladder is called cholecystitis,
Most common complication is cholecystitis; can also cause
and an infection of an obstructed common bile duct is
acute pancreatitis, acute cholangitis.
called cholangitis, or ascending cholangitis.
Diagnose with ultrasound. Treat with elective cholecystectomy
if symptomatic.
Initially gallstone disease is treated with spasmolytics such as
butylscopolamine or in severe cases with opioids such
as buprenorphine to stop the gallbladder from contracting in
order to ease the pain. After that, a cholecystectomy - which is
surgical removal of the gallbladder - can be
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, Ana de Luca
done. Cholecystectomy is curative, meaning that once it’s done, If the ERCP is successful, then gallstones are able to more easily
no further medication is needed. pass into the duodenum. After that, a cholecystectomy can be
performed to eliminate the risk of another gallstone getting stuck
Choledocolithiasis in the common bile duct.
A stone gets stuck in the common bile duct.
Cholecystitis
In choledocolithiasis, bile accumulates behind the obstruction, There’s acute cholecystitis and chronic cholecystitis and they are
which blocks the ow of the entire biliary tree and, in some both invariably related to gallstones, but sometimes, acute
cases, can back up into the liver resulting in jaundice. cholecystitis may appear in individuals without gallstones - that’s
Other symptoms include abdominal pain in the right upper called acalculous cholecystitis- and it’s caused by bile stasis.
quadrant that lasts for more than one hour, nausea and
vomiting. With CHRONIC cholecystitis, gallstones block the cystic duct
and then get dislodged and then again can block the cystic duct
On clinical examination, Courvoisier’s sign may be present, and get dislodged. This cycle can happen over and over, and
meaning there’s a palpable gallbladder. This happens as a result each time it causes in ammation that may result in recurrent
of the obstruction of the common bile duct which makes the episodes of right upper quadrant pain.
gallbladder dilate.
- Courvoisier’s sign is usually associated with malignant common Sometimes, probably because of the intermittent injury to the
bile duct obstruction, but it can also appear gallbladder, its walls can get calci ed and this is called a
in choledocolithiasis. porcelain gallbladder which increases the risk for
developing gallbladder carcinoma.
Blood tests will show leukocytosis, and because of cholestasis,
(blocked ow in the common bile duct to the duodenum) → total A porcelain gallbladder can be seen on an abdominal
bilirubin is high, especially direct or conjugated bilirubin, also radiography as a well contoured balloon or on an ultrasound
alkaline phosphatase and gamma glutamyl transferase levels where the gallbladder shows dense shadowing that can be
are high. mistaken for gallstones.
To diagnose choledocolithiasis, a right upper quadrant
ultrasound is done, and typically shows a dilated common bile
duct and intrahepatic bile ducts.
If the ultrasound is inconclusive, a magnetic resonance
cholangiopancreatography or MRCP can be performed to con rm
the diagnosis. MRCP is a noninvasive technique that uses
contrast or noncontrast MRI imaging.
Treatment of choledocolithiasis starts with intravenous uids to
prevent dehydration and antibiotics while the biliary tree is With ACUTE cholecystitis, the symptoms are usually severe and
in amed and more susceptible to an infection. the individual has a fever, loss of appetite, and pain in the right
upper quadrant, which can radiate to the shoulder or back
To remove the gallstones, a procedure called endoscopic especially after a high-fat meal.
retrograde cholangiopancreatography or ERCP is used. - Typically, the pain is constant and severe and it usually starts
With ERCP, a long, exible tube is inserted through the mouth, as a biliary colic, but it can last up to 6 hours and is associated
down the esophagus, through the stomach and in the duodenum. with anorexia, nausea, and vomiting, as well as a mild fever and
Once it gets there, a cannula is passed through the ampulla of leukocytosis.
Vater and a sphincterotomy, a small cut, is made above it, Murphy’s sign - which is where an examiner rmly places their
where Oddi’s sphincter is located. Finally, a small balloon is hand in the right upper abdominal quadrant under the liver border
in ated in the sphincter to further dilate the common bile duct. and asks the individual to breathe in. If the pain worsens, it’s
fl
fl flfl fl fi fi fl fi
Gallblader and Gallstones: risk factors → 4F’s → fat, female, fertile and fory.
- Progesterone inhibits galllblader motility.
pancreas - Pigment stones are composed of bilirrubin and are secondary
to RBC turnover → ex: patient with sicke cell anemia and RUQ
Anatomy pain may have cholelithiasis.
- Asymptomatic found on ultrasound require no treatment.
The gallbladder is a small, pouch-like organ that stores the bile
- Symptomatic cholelithiasis → elective surgery.
produced by the liver.
- Cholecystitis → atb. and urgent attention.
- Choledocholithiasis is the stone impactation within the
After a fatty meal, the gallbladder contracts and releases bile to
common Bille duct and can lead to cholangitis, which is the
help break down fats in the diet.
ascending infection of the biliary tree → endoscopic removal
via ERCP + IV antibiotics.
Bile is made up mostly of water, bile salts, bilirubin, fats and
as cholesterol.
Symptomatic Cholelithiasis (Biliary Colic)
Now, the most common gallbladder diseases have to do with an
Gallstones, when symptomatic, cause colicky RUQ pain after
imbalance in bile uid composition, which leads to the formation
fatty meals when the gallbladder contracts against a stone
of stones either in the gallbladder or somewhere along the biliary
lodged in the cystic duct under the stimulation of CCK.
tree.
Murphy’s sign will not be present.
2 types of stones:
1. Cholesterol stones → associated with obesity, Crohn
disease, advanced age, estrogen therapy, multiparity, rapid
weight loss, medications (eg, brates).
2. Pigment stones → associated with Crohn disease, chronic
hemolysis, alcoholic cirrhosis, advanced age, biliary
infections, total parenteral nutrition (TPN).
For most asymptomatic individuals, the usual plan is watchful
waiting. However, for symptomatic individuals or those at high
risk for developing symptoms, treatment is necessary.
A gallstone in the gallbladder is called cholelithiasis, and
- High risk individuals include those with hemolytic
a gallstone in the common bile duct is
disorders like sickle cell disease, morbidly obese individuals
called choledocolithiasis, and both are associated with mild
who undergo gastric bypass or individuals who have risk
in ammation. But, if the gallstones block the normal bile ow this
factors for developing gallbladder cancer,
can cause severe in ammation in the biliary tree.
like gallstones bigger than 3 centimeters, a
calci ed gallbladder wall, also called a porcelain
When there’s a lot of in ammation, the gallbladder and common
gallbladder, and gallbladder adenomas.
bile duct tissue becomes extremely susceptible to infection. An
infection of an obstructed gallbladder is called cholecystitis,
Most common complication is cholecystitis; can also cause
and an infection of an obstructed common bile duct is
acute pancreatitis, acute cholangitis.
called cholangitis, or ascending cholangitis.
Diagnose with ultrasound. Treat with elective cholecystectomy
if symptomatic.
Initially gallstone disease is treated with spasmolytics such as
butylscopolamine or in severe cases with opioids such
as buprenorphine to stop the gallbladder from contracting in
order to ease the pain. After that, a cholecystectomy - which is
surgical removal of the gallbladder - can be
fl fi fl fl fl fi fl
, Ana de Luca
done. Cholecystectomy is curative, meaning that once it’s done, If the ERCP is successful, then gallstones are able to more easily
no further medication is needed. pass into the duodenum. After that, a cholecystectomy can be
performed to eliminate the risk of another gallstone getting stuck
Choledocolithiasis in the common bile duct.
A stone gets stuck in the common bile duct.
Cholecystitis
In choledocolithiasis, bile accumulates behind the obstruction, There’s acute cholecystitis and chronic cholecystitis and they are
which blocks the ow of the entire biliary tree and, in some both invariably related to gallstones, but sometimes, acute
cases, can back up into the liver resulting in jaundice. cholecystitis may appear in individuals without gallstones - that’s
Other symptoms include abdominal pain in the right upper called acalculous cholecystitis- and it’s caused by bile stasis.
quadrant that lasts for more than one hour, nausea and
vomiting. With CHRONIC cholecystitis, gallstones block the cystic duct
and then get dislodged and then again can block the cystic duct
On clinical examination, Courvoisier’s sign may be present, and get dislodged. This cycle can happen over and over, and
meaning there’s a palpable gallbladder. This happens as a result each time it causes in ammation that may result in recurrent
of the obstruction of the common bile duct which makes the episodes of right upper quadrant pain.
gallbladder dilate.
- Courvoisier’s sign is usually associated with malignant common Sometimes, probably because of the intermittent injury to the
bile duct obstruction, but it can also appear gallbladder, its walls can get calci ed and this is called a
in choledocolithiasis. porcelain gallbladder which increases the risk for
developing gallbladder carcinoma.
Blood tests will show leukocytosis, and because of cholestasis,
(blocked ow in the common bile duct to the duodenum) → total A porcelain gallbladder can be seen on an abdominal
bilirubin is high, especially direct or conjugated bilirubin, also radiography as a well contoured balloon or on an ultrasound
alkaline phosphatase and gamma glutamyl transferase levels where the gallbladder shows dense shadowing that can be
are high. mistaken for gallstones.
To diagnose choledocolithiasis, a right upper quadrant
ultrasound is done, and typically shows a dilated common bile
duct and intrahepatic bile ducts.
If the ultrasound is inconclusive, a magnetic resonance
cholangiopancreatography or MRCP can be performed to con rm
the diagnosis. MRCP is a noninvasive technique that uses
contrast or noncontrast MRI imaging.
Treatment of choledocolithiasis starts with intravenous uids to
prevent dehydration and antibiotics while the biliary tree is With ACUTE cholecystitis, the symptoms are usually severe and
in amed and more susceptible to an infection. the individual has a fever, loss of appetite, and pain in the right
upper quadrant, which can radiate to the shoulder or back
To remove the gallstones, a procedure called endoscopic especially after a high-fat meal.
retrograde cholangiopancreatography or ERCP is used. - Typically, the pain is constant and severe and it usually starts
With ERCP, a long, exible tube is inserted through the mouth, as a biliary colic, but it can last up to 6 hours and is associated
down the esophagus, through the stomach and in the duodenum. with anorexia, nausea, and vomiting, as well as a mild fever and
Once it gets there, a cannula is passed through the ampulla of leukocytosis.
Vater and a sphincterotomy, a small cut, is made above it, Murphy’s sign - which is where an examiner rmly places their
where Oddi’s sphincter is located. Finally, a small balloon is hand in the right upper abdominal quadrant under the liver border
in ated in the sphincter to further dilate the common bile duct. and asks the individual to breathe in. If the pain worsens, it’s
fl
fl flfl fl fi fi fl fi
