GALLBLADDER DISEASE

This is a review lecture for final year students attached to the University unit &
students preparing for exams. This is not meant for initial study.
Prepared by Dr Dale Maharaj, Lecturer, UWI (updated 05.12.05.)
There are 4 main disease entities:
Gallstones (Cholelithiasis)
Cholecystitis
Choledocholithiasis
Cholangitis
CHOLELITHIASIS
Def: Presence of stones in the Gallbladder-Can be asymptomatic or symptomatic
Risk factors:
Fair, Female (estrogen cholesterol uptake by liver), Fat ( HMG CoA reductase cholesterol
synthesis), Fertile, Forty, Flatulent
Oral contraceptives & HRT
Hispanics, Pima indians
Crohns ( ileal resorption of bile salts)
Hemolytic diseases (sickle cell diseases, spherocytosis)
Rapid Wt loss (Gastric bypass)
Etiology:
Cholesterol stones supersaturation theory
Pigment stones in haemolytic conditions
CHOLECYSTITS
Def: Inflammation of the gallbladder- 75% associated with bacterial infection
Acalculous - 10%
Calculus - 90%
Acalculous cholecystitis: associated with biliary stasis as with:
Major surgery
Burns
Severe trauma
Prolonged fasting
Calculous Cholecystitis: etiology follows that of cholelithiasis

Clinical Features of Cholecystits:

History
1. Pain in epigastrium or right upper quadrant
2. Initial pain of biliary colic but then becomes constant peritoneal irritation
biliary colic is not a true colic
3. Nausea, vomiting
4. Initiated by fatty meal (or history of fatty food intolerance). {postprandial CCK +
cholinergic cephalic phase of foregut motility isometric contraction)
5. Past history of gallstones or misdiagnosed PUD
Examination
1. Fever, tachycardia
2. Mild jaundice or scleral icterus (bilirubin= 2.5mg/dl) due to edema of the CBD
3. Tenderness and/or guarding in RUQ
4. Murphy sign cessation of inspiration on palpation of the right upper quadrant
5. Palpable gallbladder
6. Boas Sign
7. Fever + Jaundice + RUQ pain = Charcots Triad + (Altered mental status +
Hypotension = pentad of Reynolds)
INVESTIGATIONS
1. Elevated WBC (if > 15000 consider perforation)
2. Elevated LFTs
3. Mild elevation of amylase
4. Blood cultures if septic
5. Urinalysis to exclude UTI
6. PT/PTT especially with jaundice
7. Supine Abdominal Xray - 10% radiopaque due to rings of calcium (onion ring).
Renal calculi more homogenous appearance and posterior on lateral film. Also
look for porcelain gallbladder or air in biliary tree
8. CXR - pneumoperitoneum
9. Ultrasonography a. Gallstones or biliary sludge
b. Gallbladder distension
c. Gallbladder wall thickening (>4 mm)
d. Pericholecystic fluid
e. Intramural gas (gangrenous cholecystitis)
f. Sonographic Murphy sign
g. Stones in the CBD
10. Abdominal CT can pick up cholecystits and its complications but can miss
stones in 20% of cases
11. Biliary scintigraphy (hepatoiminodiacetic acid (HIDA), diisopropyl iminodiacetic
acid (DISIDA) functional test; should not be used in jaundice
12. ERCP more useful in cases of Choledocholithiasis
13. MRCP visualize the entire biliary tree
Tests 10-12 seldom used in simple cholecystits

TREATMENT
1. NPO and NGT (stomach decompression)
2. Intravenous rehydration
3. Analgesia (avoid morphine)
4. Intravenous antibiotics - broad-spectrum antibiotic (E coli and Bacteroides
fragilis and Klebsiella, Enterococcus, and Pseudomonas)
Surgery
Traditionally: Once patient settles on conservative treatment treat as outpatient then
perform elective open or laparoscopic cholecystectomy performed when inflammation
settles (after a few weeks)
Currently: Cholecystectomy may be performed within the first 48 hours by experienced
surgeons
OPERATION open or laparoscopic
1. Identification of Calots triangle
2. Ligation of cystic artery then duct
3. Assessment of CBD diameter and stones
4. Removal of gallbladder off liver bed
Complications of Cholecystitis or gallstones
1. Cholangitis
2. Pancreatitis
3. Gallbladder perforation
4. Gallstone ileus (stone > 2cm)
5. Gallbladder enteric fistula
6. Choledocholithiasis (10%)
7. Mucocele
8. Empyema