Today we'll discuss disorders of the biliary
system specifically about gallstone diseases.
So we'll start with a case.
A 25-year-old woman with
no known medical history
presents to urgent care with
intermittent right upper quadrant pain.
In the past 2 weeks, she has had several episodes
of pain after eating which last for a few minutes.
Today, she had an episode of severe
right upper quadrant pain with nausea,
which resolved after 30 minutes.
She takes no medications.
Her vitals are normal,
abdominal exam is unremarkable.
Her lab studies including a CBC,
lipase and hepatic panel are normal.
Ultrasound of the right upper quadrant shows
gallbladder stones without ductal dilatation.
So what is the best next step in management?
So let's point out that she has
intermittent right upper quadrant pain,
after eating which typically
last for a few minutes.
Her normal vitals exam and
labs are all quite reassuring.
And her right upper quadrant ultrasound
shows the presence of gallstones.
So, let's now discuss gallstone disease.
So there are two types of gallstone disease:
First you may have "cholelithiasis" which is
when you have a stone in the gallbladder
and the term "choledocholithiasis"
refers to a stone in the common bile duct.
So now let's review the different
terminology for gallstone diseases.
I always found this to be quite confusing
so we're gonna break it down step by step.
The first term is when you have a gallstone
in the gallbladder without any obstruction.
This is called asymptomatic cholelithiasis.
Patients often have a normal hepatic panel.
You can detect the diagnosis by ultrasound,
and treatment is just with observation.
Next if that stone in the gallbladder
causes obstruction every now and then,
this can lead to the development of biliary
colic, or just pain that occurs intermittently.
This is what's called
Again, they will have
a normal hepatic panel.
You can diagnose them by ultrasound.
And the treatment in this case
is with an elective cholecystectomy.
Lastly, you may have a stone that is now
blocking the common bile duct.
So now this is choledocholithiasis.
These patients may have an elevation or
cholestatic pattern elevation in the hepatic panel.
The imaging can be done with either an
MRCP which we'll talk about later, or ultrasound.
And treatment is with removal of that stone with
a procedure called an ERCP and a sphincterotomy.
So, how do patients with
cholelithiasis typically present?
We talked about the term biliary colic which
is this acute onset of upper abdominal pain,
usually lasting for several
minutes to several hours,
is often accompanied by nausea and vomiting
and these episodes tend to be
self-limited and occur in relation to eating.
So again, recall that this is from a gallstone becoming
impacted or obstructing the gallbladder temporarily.
So patients who have cholelithiasis
may either be asymptomatic
or they may develop symptoms
that presents with biliary colic.
The diagnosis is made by a right upper
quadrant ultrasound to detect gallstones.
And treatment depends on
whether or not they have symptoms.
So if they are asymptomatic,
you simply observe them.
However if they have symptoms, then
you perform an elective cholecystectomy.
This is just an elective surgery
where we remove the gallbladder.
So there are several different types of
gallstones that you may be tested on.
The first type is cholesterol
or mixed gallstones.
These tend to be
associated with female gender,
advanced age and certain
indigenous populations in the Americas.
These are shown by panel A
You may also have pigmented gallstones associated
with hemolysis, cirrhosis or disease of the ileum.
These are shown in panels B and C
So now let's return to our case.
A 25-year-old woman with intermittent
right upper quadrant pain after eating.
She has a normal vitals exam and labs and her
ultrasound shows gallstones.
So, we now know that her intermittent pain
associated with eating is considered biliary colic.
Her normal exam and labs are
reassuring against acute cholecystitis.
And again, her ultrasound shows evidence
of gallstones but no evidence of cholecystitis
So, she now has fallen into the
category of symptomatic cholecystitis
and the best next step in management would
be to refer her for an elective cholecystectomy.