Cholelithiasis, Emergency Medicine

Basics

Description

Symptoms arise when gallstones pass through the cystic or common bile ducts leading to impedance of normal bile flow and gallbladder spasm.
Biliary dyskinesia produces symptoms identical to biliary colic in the absence of stones.
Choledocholithiasis (common bile duct stones), may lead to prolonged pain, elevated LFTs and bilirubin, and to more complications like cholangitis or pancreatitis.

Etiology

Cholesterol stones:
- Most common type of gallstone
- Form when solubility exceeded
Pigment stones:
- 20%
- Composed of calcium bilirubinate
- Associated with clinical conditions such as hemolytic anemias that lead to increased concentration of unconjugated bilirubin
Incidence increases with age and favors females to males 2:1. Other risk factors include Hispanic ethnicity, obesity, pregnancy, rapid weight loss, and drugs that induce biliary stasis (e.g., ceftriaxone and oral contraceptives).
Gallstones are exceedingly rare in childhood and are most commonly associated with sickle cell disease, hereditary spherocytosis, or other hemolytic anemias that result in pigment stone formation.
Biliary sludge:
- Nonstone, crystalline, granular matrix
- Associated with rapid weight loss, pregnancy, ceftriaxone or octreotide therapy, and organ transplantation
- May develop symptoms identical to cholelithiasis and its complications
"Porcelain gallbladder" from mucosal precipitation of calcium salts owing to recurrent obstruction of cystic duct.

Diagnosis

Signs and Symptoms

History

Dull, aching epigastric or right upper quadrant (RUQ) pain:
- Arising over 2-3 min, continuous (rather than colicky), and lasting from 30 min-6 hr before dissipating
- May radiate to the tip of right scapula, acromion, or thoracic spine
- Often correlated with ingestion of large, fatty meal
Anorexia
Nausea and vomiting
Afebrile:
- Fever and chills suggest cholecystitis or cholangitis

Physical Exam

Tenderness to deep palpation but without rebound
Murphy sign (inspiratory arrest during deep palpation of the RUQ) may be present during the episode of colic, but should resolve when symptoms pass.

Essential Workup

Obtain ECG on those whose pain may be owing to myocardial ischemia.
CBC
LFTs
Amylase, lipase
Urinalysis
Human chorionic gonadotropin (hCG)

Diagnosis Tests & Interpretation

Lab

CBC:
- WBC count usually normal, but may elevate after vomiting
- Leukocytosis suggestive of cholecystitis or cholangitis
LFTs:
- Usually normal
- Elevation suggests common duct obstruction, cholangitis, cholecystitis, or hepatitis.
Amylase/lipase
- Normal or minimally elevated with passage of gallstone
- Elevation in context of severe persistent epigastric pain suggests pancreatitis.
Urinalysis:
- Exclude nephrolithiasis or pyelonephritis.
- Bilirubinuria suggests common duct obstruction or hepatitis.

Imaging

US:
- Detects gallstones with sensitivity and specificity >90%
- Dilation of common bile duct >10 mm indicates obstruction, but no dilation may be present with acute obstruction.
- Gallbladder wall thickening >5 mm or pericolic fluid 90% sensitive and 80% specific for cholecystitis
- Accuracy enhanced in fasting patient (>6 hr) with noncontracted gallbladder
Radionuclide scanning (HIDA):
- Cannot detect gallstones
- Passage of tracer into small intestine without visualization of gallbladder highly diagnostic of cystic duct obstruction and cholecystitis:
  - Sensitivity and specificity roughly 95%
- Failure of tracer to pass into duodenum suggests common bile duct obstruction. Accuracy enhanced by morphine injection during scan causing sphincter of Oddi spasm and improving gallbladder filling.
CT scanning:
- Less sensitive than US to detect gallstones:
  - Only 20% radiopaque.
- Most useful to exclude other causes of upper abdominal pain such as aortic aneurysm, perihepatic abscess, or pancreatic pseudocyst
- Detects rare complications such as air in gallbladder wall in emphysematous cholecystitis, air-filled gallbladder in biliary-enteric fistula or a "Porcelain gallbladder."
Plain radiographs:
- Most useful for diagnosis of intestinal obstruction or rare abnormalities such as air in gallbladder wall in emphysematous cholecystitis, air-filled gallbladder in biliary-enteric fistula or a "Porcelain gallbladder."

Differential Diagnosis

MI
Abdominal aortic aneurysm
Acute cholecystitis, cholangitis, or choledocholithiasis
Renal colic or pyelonephritis
Duodenal ulcer perforation
Acute pancreatitis
Intestinal obstruction
Peptic ulcer disease, gastritis, or GERD
Right lower lobe pneumonia, pleurisy, or pulmonary infarction
Hepatitis or hepatic abscess
Fitz-Hugh and Curtis syndrome

Treatment

Pre-Hospital

Initiate IV access for patients with nausea or vomiting.

Initial Stabilization/Therapy

IV fluid bolus if vomiting or hypotensive

Ed Treatment/Procedures

IV hydration with 0.9% NS if vomiting
NPO
Parenteral NSAIDs (ketorolac) may lessen biliary spasm, but may exacerbate peptic causes of pain.
Narcotic analgesics (hydromorphone) with antiemetic (ondansetron):
- Administer for refractory pain once diagnosis is reasonably established.
- Morphine sulfate may lead to spasm at sphincter of Oddi (clinical significance not well established).
Anticholinergics (glycopyrrolate) have no proven benefit in the treatment of acute biliary pain.

Medication

Ketorolac: 60 mg IM or 30 mg (peds: Start 0.5 mg/kg for 1st dose up to 1 mg/kg/24h) IV q6h. In elderly: 30 mg IM or 15 mg IV
Hydromorphone: 0.5-2 mg IV (0.01-0.02 mg/kg), titrated to pain relief.
Ondansetron: 4-8 mg IV (0.15-0.3 mg/kg) IV (not to exceed 8 mg/dose IV), q4h PRN vomiting.

Follow-Up

Disposition

Admission Criteria
Admission and surgical or gastroenterologic consultation for evidence of:

Acute cholecystitis
Acute cholangitis
Common duct obstruction
Gallstone pancreatitis

Discharge Criteria

Lack of clinical, lab, or radiographic evidence of cholecystitis, cholangitis, common duct obstruction, or pancreatitis
Resolution of all pain and tenderness
Ability to tolerate oral fluids

Issues for Referral

General surgery referral for all cases of biliary colic with documented cholelithiasis or for radiographic finding of a "Porcelain gallbladder" (due to increased risk of gallbladder carcinoma).
GI referral for choledocholithiasis.

Followup Recommendations

Surgical follow-up for patients with symptomatic gallstones

Pearls and Pitfalls

Alternative causes of upper abdominal pain may be falsely attributed to incidental finding of gallstones.
An ultrasound is more sensitive and specific for cholelithiasis.
Radionuclide scanning (HIDA) is highly diagnostic of cystic duct obstruction and cholecystitis.
CT scans may miss gallstones if the stones are not radiopaque.

Additional Reading

Antevil JL, Buckley RG, Johnson AS, et al. Treatment of suspected symptomatic cholelithiasis with glycopyrrolate: A prospective, randomized clinical trial. Ann Emerg Med. 2005;45:172-176.
Jackson PG, Evans SR. Biliary system. In: Townsend CM Jr, ed. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: WB Saunders; 2012:1476-1514.
Silen W, ed. The colics. Copes Early Diagnosis of the Acute Abdomen. 22nd ed. Oxford, UK: Oxford University Press; 2010:145-153.
Strasberg SM. Acute calculous cholecystitis. N Eng J Med. 2008;358:2804-2811.
Vassiliou MC, Laycock WS. Biliary Dyskinesia. Surg Clin North Am. 2008;88(6):1253-1272.

Codes

ICD9

574.20 Calculus of gallbladder without mention of cholecystitis, without mention of obstruction
574.21 Calculus of gallbladder without mention of cholecystitis, with obstruction
574.90 Calculus of gallbladder and bile duct without cholecystitis, without mention of obstruction
574.91 Calculus of gallbladder and bile duct without cholecystitis, with obstruction
574.2 Calculus of gallbladder without mention of cholecystitis

ICD10

K80.20 Calculus of gallbladder w/o cholecystitis w/o obstruction
K80.21 Calculus of gallbladder w/o cholecystitis with obstruction
K80.70 Calculus of GB and bile duct w/o cholecyst w/o obstruction
K80.71 Calculus of GB and bile duct w/o cholecyst w obstruction
K80.2 Calculus of gallbladder without cholecystitis
K80.7 Calculus of gallbladder and bile duct without cholecystitis

SNOMED

266474003 calculus in biliary tract (disorder)
235919008 gallbladder calculus (disorder)
312110005 gallbladder and bile duct calculi (disorder)
168037002 On examination - cholesterol gallstone (disorder)

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