Welcome back. Thanks for joining me on this discussion of gallbladder. Well, we will discuss
cholelithiasis, cholecystitis, and cholangitis. Symptomatic cholelithiasis involves the formation
of lots of gallstones. In this picture, you see the entire gallbladder replaced with large gallstones.
In symptomatic cholelithiasis, these gallstones only cause periodic obstruction. This periodic
obstruction can cause distension of the gallbladder. We need to differentiate this
from cholecystitis pathophysiology where once again, gallstones are present.
However, this time the cystic duct obstruction is not intermittent. I would like to pose
a question to you. Given that the vast majority of patients with gallstones are asymptomatic,
what changes do cause them to become symptomatic? I’ll give you a second
to think about this. The answer is cystic duct obstruction. That’s right. Whether it’s symptomatic
cholelithiasis in that there’s intermittent obstruction or acute cholecystitis, where there is a
chronic obstruction, these are in common when patients develop symptoms. What are the symptoms
of cholelithiasis, symptomatic as well as cholecystitis? Well, abdominal pain particularly
postprandial described classically after a fatty meal. This pain can be described as colicky or crampy
in the right upper quadrant. If it’s not acute cholecystitis, it’s usually self-limited. Patients can describe
significant nausea and vomiting. This likely is due to the close approximation of the gallbladder
with the proximal GI system namely the duodenum and stomach. Patients can also describe
lack of appetite or food fear because every time they eat, they get this significant postprandial pain.
Common physical findings include a Murphy sign. A technical definition of Murphy sign is an arrest
of inspiration while deeply palpating the right upper quadrant. This is suggestive of peritoneal
irritation with the descent of the gallbladder. As the patient inspires, the diaphragm drops down
on the right side. Dropping of the diaphragm stretches the peritoneum and causes the pain
when there’s an infection of the gallbladder. What are some things that you’ll find
on laboratory evaluation? Generally speaking, the chemistries are going to be normal.
When one looks at the CBC, there may be an elevation of the white count
that happens in cases of cholecystitis.
Furthermore, when liver function tests are looked at, total bilirubin is generally normal
unless there is a common bile duct obstruction. Similarly, alkaline phosphatase is going to be normal.
AST and ALT may be normal except in severe cases of cholecystitis where the liver may be irritated locally.