Gallstones: Diagnosis and Management

by Carlo Raj, MD

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    00:02 Diagnosis. Right upper quadrant tenderness we talked about, along with this, there’s something called Murphy’s sign.

    00:08 What does that mean? It means that the pain is then going to shoot up into the right scapula for the Murphy’s sign.

    00:15 The gallbladder is usually not palpable. Leukocytosis and elevated liver function test. Now, we’re getting to interesting labs.

    00:23 If in fact it is going to be issues in the biliary tree, what’s the enzyme that you’re paying attention to? Alkaline phosphatase.

    00:32 If you have issues in the liver, you have alk phos and liver function test, such as transaminases elevated.

    00:39 Let me give you another one. What if it was alk phos and lipase? Where is my stone, please? The stone has moved down to the common bile duct.

    00:49 Not only do I have problems with the biliary tree, but I also have damage and pathology to the pancreas.

    00:57 Things that you’re worried about, blood cultures show E.coli.

    01:00 Gram-negative organisms we talked about. Maybe even Clostridium.

    01:05 Imaging. The type of radiology and imaging study that you’d use, ultrasound.

    01:11 The gallstones are symptoms that you would find inside my gallbladder.

    01:15 In addition, remember, if the gallbladder has been obstructed, you can imagine that the gallbladder wall has become inflamed. Therefore, you’d expect to find thickening and edema of the gallbladder wall.

    01:27 In fact, histologically, when the gallbladder has become thickened and cholecystitis continues, at some point in time -- have you heard? I know that you have. In medical school and during your education, you’ve heard of something called porcelain gallbladder.

    01:44 What color is porcelain? White.

    01:47 Gallbladder is not that color normally. So what is then contributing to the whitishness of the gallbladder, the porcelain? The thick wall at some point might start eroding.

    02:01 If you have erosion, there's s a term, that will be called or known as Rokitansky, Rokitansky type of sinus. And with that Rokitansky type of sinus that develops, you might have calcium accumulating, and this is dystrophic calcification.

    02:19 Calcium is what color? White.

    02:22 Ultrasound will show you gallstones in the gallbladder, thickening of that wall with edema. And you have something called your dilated biliary tree.

    02:32 You’re going to like this one. You’re going to bring in some anatomy, you’re going to know some physio, and we’re going to use pathology so that we can use something called a HIDA scan. Pay attention.

    02:48 Stone, gallbladder, think about what that is.

    02:53 Contraction, obstruction, cholecystitis, maybe Rokitansky type of sinus that we talked about.

    03:00 Ultrasound is going to help you identify the gallstone.

    03:04 Now, here’s my problem. I don’t find a stone.

    03:07 Oh, boy. I don’t find a stone perhaps in the gallbladder.

    03:12 But you know there’s obstruction based on the symptoms of your patient.

    03:16 But you don’t know where the stone is.

    03:18 You don’t know if the stone is located in the cystic duct or if the stone is down the common bile duct.

    03:24 If you’re not clear about this anatomy, I mentioned this earlier, I asked you kindly to make sure that you’re familiar with at least the basic anatomy here to walk us through these type of imaging studies that you’ll be asked about on your boards.

    03:39 Your HIDA scan. Remember, from the liver is where bile synthesis takes place.

    03:45 It will be taken to the bile duct in the liver, out of the liver, and into the gallbladder, normally.

    03:53 What if you had a method by which you injected a dye, hepatic endo-diacetic acid.

    03:59 You had a dye. HIDA stands for hepatic endo-diacetic acid.

    04:03 Do not worry about the name per se.

    04:06 It’s the dye that you’re putting into the liver.

    04:08 You’re going to radiographically follow the dye and see as to whether or not it should end up in your gallbladder. Are you with me? What if the stone is in the cystic duct? Go back and take a look at the anatomy.

    04:25 If that stone is in cystic duct, is that dye going to make its way from the liver to the gallbladder? No.

    04:36 Therefore, useful in doubtful cases of cholecystitis, because this will tell you if the cholecystitis was being caused by a stone in the cystic duct. And if the dye doesn’t make it in the gallbladder, this confirms that your stone and the cholecystitis was caused by the stone in the cystic duct.

    04:57 It couldn’t be any clearer than that. If that still remains confusing, go back and review what I just said here because that part, I guarantee, you’ll be asked about that in some way, shape, or form.

    05:09 Ultrasound, HIDA scan. Ultrasound of the gallbladder.

    05:14 That arrow that we’re seeing here on the ultrasound is actually showing you a stone within the gallbladder.

    05:21 Let’s take a look at the management of gallstones.

    05:25 Patient comes in and says, “Hey, doc, I had a piece of steak and, aw, it hurts.” “Where?” “Right upper quadrant pain.” He asked a surgeon and what does he or she want to do? Cholecystectomy, remove it. However, you will go and step further.

    05:40 Your patient is not, NOT, symptomatic. Therefore, you will not be doing surgery, period.

    05:47 Elective surgery is a possibility if there’s complications.

    05:53 Next, whenever there are issues within or -itis in general, IV antibiotics and hydration because you’re worried about once again, sepsis.

    06:03 Percutaneous drainage for acalculous type of cholecystisis and ERCP, an urgent type of decompression, with what’s known as a sphincterotomy, in which you try to then evacuate the stone as quickly as possible, especially if he's then prone to pancreatitis.

    06:23 Remember when to use a HIDA scan and when to do an ERCP.

    06:27 HIDA scan is when you find a cholecystitis and you’re doubtful about where the stone is and you find it in the cystic duct.

    06:35 And ERCP would be one in which emergency-wise, you try to remove the stone as quickly as possible so that you allow for proper flow of your bile and your pancreatic enzymes into the duodenum.

    About the Lecture

    The lecture Gallstones: Diagnosis and Management by Carlo Raj, MD is from the course Pancreatic and Biliary Tract Diseases.

    Included Quiz Questions

    1. Stone is present at the sphincter of Oddi
    2. Stone is impacted at the cystic duct
    3. Stone is impacted at the left hepatic bile duct
    4. Stone is impacted at right hepatic duct
    5. Stone is impacted at the neck of the gallbladder
    1. Porcelain gallbladder
    2. Gallbladder with gallstone
    3. Acute cholecystitis
    4. Chronic cholecystitis
    5. Cholesterolosis of gallbladder
    1. Abdominal tenderness and pain radiating to the right shoulder
    2. Abdominal tenderness and pain radiating to the left shoulder
    3. Pain when the examiner releases the hand after applying pressure
    4. Abdominal tenderness radiating to the umbilicus
    5. Pain in the abdominal area when legs are extended
    1. Proteus mirabilis
    2. E. coli
    3. Klebsiella
    4. Group D streptococci
    5. Clostridium
    1. Strawberry appearance of the wall of the gallbladder
    2. Gallstones
    3. Gallbladder wall thickening
    4. Edema of gallbladder
    5. Dilated biliary tree
    1. HIDA scan
    2. MRCP
    3. ERCP
    4. Repeat ultrasound scan
    5. X-ray
    1. "Cholecystectomy is done if a person is symptomatic."
    2. " Cholecystectomy cannot be done as an elective procedure."
    3. "Emergency cholecystectomy must be considered for your presentation."
    4. "Cholecystectomy is a futile procedure and the stone will not cause any symptoms in the future."
    5. "Cholecystectomy is a risky and complicated procedure. However, I will perform it with ease on you."
    1. MRCP is the procedure of choice for decompression and sphincterotomy
    2. Percutaneous drainage is done for acalculous cholecystitis
    3. Cholecystectomy is avoided in patients who are asymptomatic
    4. Elective cholecystectomy has a significantly lower complication rate
    5. IV antibiotics and hydration are recommended for acute cholecystitis.

    Author of lecture Gallstones: Diagnosis and Management

     Carlo Raj, MD

    Carlo Raj, MD

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