QUICK RECERTIFICATION SERIES
Cholelithiasis
Jill M. Gore, MPAS, PA-C
GENERAL FEATURES
• Stones in the gallbladder (cholelithiasis) usually develop
insidiously and patients may remain asymptomatic
for years.
• Stones are composed of two main substances: cholesterol
and calcium bilirubinate. In patients in the United States,
80% of gallstones are cholesterol.
• In the United States, the prevalence of cholelithiasis is
about 5.5% for men and 8.6% for women. This rate is
higher in people over age 60 years and Hispanics.
• Common risk factors for the development of choleli-
thiasis include obesity, rapid weight loss, and insulin
resistance.
• Choledocholithiasis, which develops in about 15% of
patients with cholelithiasis, occurs when stones migrate
from the gallbladder into one of the bile ducts (usually the
common bile duct). The resulting gallbladder wall tension
leads to a characteristic pain known as biliary colic.
• Complications result from migration of gallstones and
obstruction in various biliary ducts
¡ Cystic duct obstruction leads to inflammation of the
gallbladder, known as acute cholecystitis.
¡ A stone that obstructs the common bile duct may lead
to ascending cholangitis. Blockage and stagnation of
bile leads to infection and ascension of bacteria through-
out the biliary tree and into the liver.
¡ Obstruction of the pancreatic duct triggers pancreatic
enzyme production within the pancreas and leads to
acute pancreatitis.
CLINICAL ASSESSMENT
• Commonly, patients are asymptomatic and cholelithiasis
may be an incidental finding.
• Choledocholithiasis may cause:
¡ intense spasmodic and intermittent right upper quad-
rant (RUQ) abdominal pain that can radiate to the
back or right shoulder.
¡ postprandial pain, commonly after the patient eats
fatty or greasy foods.
• If obstruction is present, the patient may complain of
fever, clay-colored stool, tea-colored urine, jaundice,
Jill M. Gore is a PA practicing in primary care in San Antonio, Texas.
The author has indicated no relationships to disclose relating to the
content of this article. Dawn Colomb-Lippa, MHS, PA-C, and Amy M.
Klingler, MS, PA-C, department editors
DOI: 10.1097/01.JAA.0000438244.25450.34
Copyright © 2013 American Academy of Physician Assistants
54 www.JAAPA.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
nausea and vomiting, pruritus, and symptoms specific
to pancreatitis.
• On examination, the patient may appear jaundiced and
RUQ tenderness may be present with palpation. A
positive Murphy sign may be elicited.
• Charcot Triad (fever, RUQ tenderness, and jaundice) is
strongly indicative of cholangitis.
DIAGNOSIS
• Cholelithiasis
¡ Ultrasound is the preferred modality and may show
stones in the gallbladder with subsequent dilation of
the duct or gallbladder wall thickening. Computed
tomography (CT) has no advantage over ultrasound.
¡ A hepatobiliary (HIDA) scan can assess for gallbladder
function and aid in diagnosing obstruction
• Choledocholithiasis
¡ Cholangiography is the gold standard for determining
common bile duct obstruction
¡ Endoscopic retrograde cholangiopancreatography
(ERCP) is the most common diagnostic modality
because it is highly sensitive and specific, and stones
can be extracted during the procedure.
¡ Magnetic resonance cholangiopancreatography (MRCP)
is the most accurate noninvasive test, with a high sen-
sitivity and specificity.
QUESTIONS
1. Which of the following is not a symptom of
choledocholithiasis?
a. jaundice
b. melena
c. tea-colored urine
d. pruritus
e. RUQ abdominal pain
2. Which of the following is the gold standard for diagnosing
common bile duct obstruction?
a. transabdominal ultrasound
b. HIDA scan
c. total bilirubin
d. ERCP/MRCP
e. abdominal CT
Volume 26 • Number 12 • December 2013
 Cholelithiasis

¡ Other imaging that may be performed includes trans-
abdominal or endoscopic ultrasound, abdominal CT,
and HIDA scan.
¡ The patient’s total bilirubin may be increased; direct
hyperbilirubinemia indicates obstruction.
¡ The patient’s AST, ALT, alkaline phosphatase, and
GGT (gamma-glutamyl transferase) likely will be
elevated.
¡ If infection is present, leukocytosis and positive blood
• Broad-coverage antibacterials are prescribed for suspected
biliary tract infection. Options include piperacillin-
tazobactam, ampicillin-sulbactam, levofloxacin, and
ciprofloxacin.
• Laparoscopic cholecystectomy is the treatment of choice
for symptomatic cholelithiasis, cholecystitis, and cho-
ledocholithiasis.

cultures may be noted.

¡ If the pancreatic duct is obstructed, elevated levels of
amylase and lipase will be seen.
TREATMENT
• Asymptomatic cholelithiasis requires no immediate
intervention. Nonsteroidal anti-inflammatory drugs may
be administered for intermittent pain. A low-fat diet may
be beneficial.
tests may be performed as part of the evaluation.
for diagnosing common bile duct obstruction. The other
2. D. Cholangiography (ERCP or MRCP) is the gold standard
Clay-colored stool, not melena, is also a symptom.
abdominal pain are all symptoms of choledocholithiasis.
1. B. Jaundice, tea-colored urine, pruritus, and RUQ
Answers

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