Case Files Surgery, (LANGE Case Files) 4th Ed.

SECTION II. Clinical Cases

CASE 8

A 46-year-old woman presents with a 24-hour history of abdominal pain that began approximately 1 hour after a large dinner. The pain initially began as a dull ache in the epigastrium but then localized in the right upper quadrant (RUQ). She describes some nausea but no vomiting. Since her presentation to the emergency department, the pain has improved significantly to the point of her being nearly pain free. She describes having had similar pain in the past with all previous episodes being self-limited. Her past medical history is significant for type 2 diabetes mellitus. On physical examination, her temperature is 38.1°C (99°F), and the rest of her vital signs are normal. The abdomen is nondistended with minimal tenderness in the RUQ. Findings from the liver examination appear normal. The rectal and pelvic examinations reveal no abnormalities. Her complete blood count reveals a white blood cell (WBC) count of 13,000/mm3. Serum chemistry studies demonstrate total bilirubin 0.8 mg/dL, direct bilirubin 0.6 mg/dL, alkaline phosphatase 100 U/L, aspartate transaminase (AST) 45 U/L, and alanine transaminase (ALT) 30 U/L. Ultrasonography of the RUQ demonstrates stones in the gallbladder, a thickened gallbladder wall, and a common bile duct (CBD) diameter of 4.0 mm.

Images What is the most likely diagnosis?

Images What is the best therapy?

Images What are the complications associated with this disease process?

ANSWERS TO CASE 8: Gallstone Disease

Summary: A 46-year-old woman presents with a 1-day history of RUQ abdominal pain and a physical examination and laboratory findings suggestive of gallstone disease.

• Most likely diagnosis: Cholecystitis, likely acute and chronic.

• Best therapy: Laparoscopic cholecystectomy is the preferred treatment for all patients with a reasonable life expectancy and no prohibitive risks for general anesthesia and abdominal surgery.

• Complications: Complications from gallstone disease include complications involving the gallbladder (acute and chronic cholecystitis) and complications involving the passage of stones from the gallbladder (including pancreatitis, choledocholithiasis, cholangitis, and gallstone ileus).

ANALYSIS

Objectives

1. Know the etiology of gallstone disease and learn the differences among biliary colic, acute cholecystitis, and chronic cholecystitis.

2. Know the basic diagnostic and therapeutic plans for patients with gallstone disease.

3. Learn the complications that can develop from gallstone disease.

Considerations

This patient provides a good history of recurrent upper abdominal pain episodes following meals, consistent with biliary colic. Although she demonstrates minimal tenderness to palpation in her right upper abdomen on physical examination, the elevated leukocyte count and ultrasound findings of gallbladder wall thickening are consistent with acute or chronic cholecystitis. If this patient had a normal WBC count and an ultrasound examination demonstrating stones in the gallbladder and no other abnormalities, the presentation would be consistent with biliary colic, which can be treated by elective cholecystectomy. Because findings in this patient are consistent with cholecystitis, the treatment consists of hospital admission, administration of intravenous antibiotics, and laparoscopic cholecystectomy prior to discharge from the hospital.

APPROACH TO: Gallstone Disease

DEFINITIONS

BILIARY COLIC: Characterized by waxing and waning, poorly localized postprandial upper abdominal pain radiating to the back and normal laboratory evaluations of liver functions. It is caused by cholecystokinin (CCK)-stimulated gallbladder contraction, following food ingestion. The condition is generally produced by gallstone obstruction at the gallbladder neck or, less commonly, by gallbladder dysfunction.

ACUTE CHOLECYSTITIS: In 95% of patients, acute cholecystitis results from a stone or stones obstructing the cystic duct. Bacterial infection is thought to occur via the lymphatics, with the most commonly found organisms being Escherichia coli, Klebsiella, Proteus, and Streptococcus faecalis. Patients generally present with persistent RUQ pain, with or without fever, gallbladder tenderness, leukocytosis, and often mild, nonspecific elevated liver enzyme levels, which may or may not indicate CBD stones. Treatment includes hospital admission, administration of intravenous fluids, nothing by mouth, antibiotics directed at the organisms just listed, and cholecystectomy during the hospitalization.

ACALCULOUS CHOLECYSTITIS: Gallbladder inflammation caused by biliary stasis (in 5% of patients with acute cholecystitis) leading to gallbladder distension, venous congestion, and decreased perfusion; it nearly always occurs in patients hospitalized with a critical illness.

CHRONIC CHOLECYSTITIS: Results from repeated bouts of biliary colic and/or acute cholecystitis leading to gallbladder wall inflammation and fibrosis. The patient may present with persistent or recurrent localized RUQ pain without fever or leukocytosis. Sonography may demonstrate a thickened gallbladder wall or a contracted gallbladder.

CHOLANGITIS: Infection within the bile ducts, most commonly caused by complete or partial obstruction of the bile ducts by gallstones or strictures. The classic Charcot triad (RUQ pain, jaundice, and fever) is seen in only 70% of patients. This condition may lead to life-threatening sepsis and multiple-organ failure. Treatment consists of antibiotic therapy and supportive care; in cases of severe cholangitis, endoscopic decompression of the bile duct by endoscopic retrograde cholangiopan-creatography (ERCP) or surgery is indicated.

RIGHT UPPER QUADRANT ULTRASONOGRAPHY: Sensitivity of 98% to 99% in identifying gallstones in the gallbladder. The examination is also useful for measuring the diameter of the CBD, which can indicate the possible presence of stones in the CBD (choledocholithiasis). When present, CBD stones are visualized less than 50% of the time with this imaging modality.

BILIARY SCINTIGRAPHY: The study of gallbladder function and biliary patency using an intravenous radiotracer. Normally the liver is visualized, followed by the gallbladder, followed by emptying of the radiotracer into the duodenum. Nonvisualization of the gallbladder in a patient with RUQ pain indicates gallbladder dysfunction caused by acute or chronic cholecystitis.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: Endoscopic CBD cannulation and direct injection of contrast material to visualize the duct. An endoscopic sphincterotomy in the duodenum during the procedure may facilitate bile drainage and the clearance of bile duct stones, which is especially useful in treating cholangitis and choledocholithiasis. The procedure requires sedation and may be associated with complication rates of 8% to 10%.

CLINICAL APPROACH

Pathophysiology

At least 16 million Americans have gallstones, and 800,000 new cases occur each year. Gallstones are categorized as either cholesterol stones or pigmented stones. Cholesterol stones are most common and form as the result of the combined effects of cholesterol supersaturation in the bile and gallbladder dysfunction. Only a small fraction (15%-20%) of patients with gallstones develop symptoms. Although it is unknown why some patients with gallstones develop symptoms whereas others do not, it is clear that those who develop symptoms are at risk for the subsequent development of complications, including acute and chronic cholecystitis, choledocholithiasis, pancreatitis, and cholangitis.

Patient Evaluation and Treatment

The evaluation in every patient should consist of a history, a physical examination, a complete blood count, liver function studies, a serum amylase determination, and RUQ ultrasonography (Table 8–1). It is important to differentiate biliary colic from complicated gallstone disease, such as acute or chronic cholecystitis, choledo-cholithiasis, cholangitis, and biliary pancreatitis, because the management varies for these conditions. For example, a patient with choledocholithiasis (CBD stone) may present with symptoms identical to those of biliary colic, but the condition may be differentiated on the basis of an elevation in serum liver enzyme levels and dilation of the CBD by ultrasound. In contrast to patients with biliary colic, who are treated by elective cholecystectomy, patients with choledocholithiasis require in-hospital observation for the development of cholangitis and early endoscopic clearance of CBD stones, in addition to cholecystectomy. A major goal in patient evaluation is to make an accurate diagnosis without using unnecessary imaging and invasive diagnostic studies. Choledocholithiasis should be suspected if the RUQ ultrasound findings include a CBD diameter greater than 5 mm in the presence of elevated liver enzyme levels. Gallstone pancreatitis should be considered in the presence of significantly elevated amylase and lipase values.

Table 8–1 • GALLSTONE DISEASE PRESENTATIONS

Images

Sometimes, acute and chronic cholecystitis may be difficult to differentiate clinically because in both cases patients may have localized tenderness over the gallbladder. When this situation arises, patients should be treated as if they had acute cholecystitis. The treatment for both acute and chronic cholecystitis is cholecystectomy. The operation of choice is a laparoscopic cholecystectomy with or without cholangiography (radiopaque dye injected into the CBD and a radiograph taken). Some surgeons selectively perform cholangiograms if the CBD is dilated and liver enzyme levels are elevated. Other surgeons obtain cholangiograms with every laparoscopic cholecystectomy performed. Patients with gallstone pancreatitis are treated with bowel rest and intravenous hydration. When the pancreatitis resolves clinically, a laparoscopic cholecystectomy can be done. Generally, patients with uncomplicated biliary pancreatitis should undergo cholecystectomy during the same hospitalization. When cholecystectomy is delayed, 25% to 30% of patients may develop recurrent bouts of pancreatitis within a 6-week period. For patients with mild pancreatitis (<3 Ransom score), the cholecystectomy may be safely performed within 48 hours after the initial hospital admission.

COMPREHENSION QUESTIONS

8.1 A 65-year-old woman presents to the emergency department with postprandial RUQ pain, nausea, and emesis over the last 12 hours. The pain is persistent and radiates to her back. She is afebrile, and her abdomen is tender to palpation in the RUQ. Sonography demonstrates cholelithiasis, gallbladder wall thickening, and a dilated CBD measuring 12 mm. Laboratory studies reveal the following values: WBC count 13,000/mm3, AST 220 U/L, ALT 240 U/L, alkaline phosphatase 385 U/L, and direct bilirubin 4.0 mg/dL. Which of the following is the most appropriate treatment at this time?

A. Admit the patient to the hospital, provide intravenous hydration, and check hepatitis serology values.

B. Admit the patient to the hospital and perform a laparoscopic cholecystectomy.

C. Admit the patient to the hospital, provide intravenous hydration, begin antibiotic therapy, and recommend ERCP.

D. Provide pain medication in the emergency department and ask the patient to follow up in the clinic.

E. Schedule the patient for laparoscopic cholecystectomy and liver biopsy.

8.2 A 28-year-old woman undergoing an obstetric ultrasound during the second trimester of pregnancy is found to have gallstones in her gallbladder. She claims to have had indigestion with frequent belching throughout her pregnancy. Which of the following is the most appropriate treatment?

A. A low-fat diet until the end of her pregnancy and then a postpartum laparoscopic cholecystectomy.

B. Elective laparoscopic cholecystectomy during the second trimester.

C. Start the patient on chenodeoxycholate.

D. Open cholecystectomy during the second trimester.

E. Follow-up after completion of her pregnancy.

8.3 A 45-year-old man is seen in the emergency center for abdominal pain. A presumptive diagnosis of acute cholecystitis is made. Which of the following findings is most consistent with this diagnosis?

A. Fever, intermittent RUQ pain, and jaundice

B. Persistent abdominal pain, RUQ tenderness, and leukocytosis

C. Intermittent abdominal pain and minimal tenderness over the gallbladder

D. Epigastric and back pain

E. Painless jaundice with a palpable and nontender gallbladder

8.4 A 69-year-old man presents with confusion, abdominal pain, shaking chills, a rectal temperature of 34°C (94°F), and jaundice. An abdominal radiograph shows air in the biliary tree. Which of the following is the most likely diagnosis?

A. Acute cholangitis

B. Acute pancreatitis

C. Acute cholecystitis

D. Acute appendicitis

E. Acute viral hepatitis

8.5 A 33-year-old otherwise healthy woman presents to the hospital with localized RUQ pain. Her temperature is 38.2°C. Her abdomen is tender locally in the RUQ. Her WBC is 12,000/mm3 and her liver function tests are all within normal limits. An ultrasound of the RUQ revealed gallstones with the gallbladder, pericholecystic fluid, and a CBD measuring 4.5 mm in diameter. What is the most appropriate management for this patient?

A. NPO, antibiotics, followed by cholecystectomy in 6 to 8 weeks

B. NPO, antibiotics, and ERCP with endoscopic drainage of the biliary tract

C. NPO, antibiotics

D. NPO, antibiotics, and laparoscopic cholecystectomy

E. Oral analgesics and antibiotics with follow-up outpatient laparoscopic cholecystectomy in 6 weeks

8.6 A 30-year-old woman presents with postprandial upper abdominal pain that has been recurrent over the past several months. She has undergone ultrasound evaluation of the gallbladder that has not demonstrated gallstones. Her liver function studies have been normal. Which of the following is the most appropriate next step for this patient?

A. Obtain a CCK-stimulated HIDA (hepatobiliary iminodiacetic acid) scan.

B. Cholecystectomy.

C. Refer patient to a gastroenterologist for treatment of irritable bowel syndrome.

D. Repeat the gallbladder ultrasound.

E. Obtain hepatitis panel to evaluate for possible viral hepatitis.

ANSWERS

8.1 C. Admission to the hospital, administration of intravenous fluids and antibiotics, and ERCP are appropriate in managing this patient. This patient’s presentation is highly suggestive of cholangitis, with the presence of a significant elevation in her liver enzyme levels, CBD dilation, and tenderness in the RUQ.

8.2 E. Reevaluation after the completion of pregnancy is appropriate for this patient, who has stones in her gallbladder and symptoms of belching and indigestion that are very likely unrelated to gallstones and may be pregnancy induced; therefore, this patient may just have asymptomatic cholelithiasis that does not require treatment. Indications for cholecystectomy in pregnancy include cholecystitis, intractable pain, and cholangitis.

8.3 B. Persistent abdominal pain, RUQ tenderness, and leukocytosis indicate acute cholecystitis. Choice A is most consistent with cholangitis, choice C is typical of biliary colic, choice D is consistent with acute pancreatitis, and choice E is consistent with obstructing neoplasm in the periampullary region.

8.4 A. Elderly patients older than 65 years who present with fever (or hypothermia), jaundice, abdominal pain, and shaking chills often have acute cholangitis (purulent infection of the biliary tract). The presence of air in the biliary tree is consistent with this illness. This is a life-threatening condition and often requires urgent surgical or endoscopic decompression of the biliary system, in addition to aggressive supportive care and broad-spectrum antibiotic therapy.

8.5 D. This patient has signs, symptoms, and finding compatible with acute cholecystitis. The treatment of acute cholecystitis consists of antibiotics and early cholecystectomy. Early cholecystectomy has been compared to delayed cholecystectomy and the investigations have shown that early operative treatment did not contribute to increase in operative complications and that early surgery resulted in the reduction in length of stay and readmissions to the hospital.

8.6 A. This patient has fairly typical signs and symptoms of biliary colic. Biliary colic is most commonly produced by the mechanical obstruction of gallbladder drainage by a gallstone; however, in a small subset of patients, these symptoms can be produced by primary gallbladder dysfunction that is not related to gallstones. This condition is referred to as biliary dyskinesia, and its presumptive diagnosis is based on classic biliary colic symptoms, absence of gallstones, and evidence of gallbladder dysfunction. Gallbladder dysfunction could be demonstrated in these patients with a HIDA scan following CCK administration. Normal gallbladders generally will demonstrate ejection fraction of more than 50% following CCK injection, and biliary dyskinesia patients may have lower ejection fraction and reproduction of symptoms with CCK injections.

CLINICAL PEARLS

Images Cholecystectomy is generally not indicated unless there is a clear link between the patient’s symptoms and gallstones or if there is objective evidence of gallbladder dysfunction (eg, a thickened gallbladder wall on ultrasonography, nonvisualization of the gallbladder on biliary scintigraphy) or gallstone-related complications.

Images In general, the treatment of cholecystitis is hospitalization, administration of intravenous antibiotics, and a laparoscopic cholecystectomy prior to discharge from the hospital.

Images Cholangitis, which can be diagnosed with Charcot triad—RUQ pain, jaundice, and fever— is life threatening. Treatment consists of antibiotics therapy, supportive care, and, in cases of severe cholangitis biliary duct, decompression via ERCP.

Images Choledocholithiasis should be suspected if the RUQ ultrasound findings include a CBD diameter >5 mm in the presence of elevated liver enzyme levels.

REFERENCES

Aboulian A, Chan T, Kaji AH, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. 2010;251: 615-619.

Chari RS, Shah SA. Biliary system. In: Townsend CM Jr, Beauchamp RD, Evers BM, et al, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, PA: Saunders Elsevier; 2008:1547-1588.

Kao LS, Liu TH. Calculous disease of the gallbladder and biliary tract. In: Miller T, Bass BL, Fabri PJ, et al, eds. Modern Surgical Care: Physiological Foundations and Clinical Applications. 3rd ed. New York, NY: Informa Healthcare; 2007:455-468.

Oddsdottir M, Pham TH, Hunter JG. Gallbladder and the extrahepatic biliary system. In: Brunicardi FC, Andersen DK, Billiar TR, et al, eds. Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2010:1135-1166.