Gallbladder Diseases (cholelithiasis, choledecholithiasis, cholecystitis, cholangitis)

Gallbaldder diseases such as cholecystitis, cholelithiasis, cholangitis taught in handwritten tutorial for USMLE. We will be looking at pathophysiology, symptoms, investigations and management.

CHOLELITHIASIS and CHOLEDECHOLITHIASIS
Two type of stones are the most common. The first is Cholesterol stone and the second is the pigmented stone. Cholesterol stone is formed due to high levels of cholesterol or not removing cholesterol fast enough. Etiology, old age, female (especially pregnant) Obesity and rapid weight loss. Also can be caused by decrease emptying of the gallbladder which leads to supersaturation of the the cholesterolel. Pathophysiology this is due to fasting state, pregnancy, spinal cord injury can decrease neurological signal to the gallbladder to contract. There are two types of pigments depending on the color. Black is due to hemolysis (sickle cell anemia and thalessemia) Brown is due to some sort of infection that is present.

Clinical signs and symptoms of Cholelithiasis
Usually asymptomatic, incidental finding. There are just a few stones in the gallbladder. No problems until the neck of the gallbladder is obstructed and this causes pain in epigastrium to the left flank which radiates to the back and the scapula. Symptoms will be associated with eating, because when eating there is contraction of the gallbladder.

Investigations for Cholelithiasis
Ultrasound investigation is the first choice where the stones can be visualized. CT/MRI to see some of the complications of cholelithiasis.

Treatment
If it is asymptomatic than there is no treatment is necessary. But if it becomes symptomatic than you can try oral bile acids, lithotripsy, but if this isn't working or unavailable then do cholecystectomy.

Complications
Gallstone Ileus there is a tract formed between gallbladder and duodenum. choledecholithiasis or pancreatitis and cholecystitis.

CHOLEDECHOLITHIASIS
Stone formation in the bile duct. Most common origin is from the cholelithiasis.

Clinical signs and symptoms
It can also remain asymptomatic, just like cholelithiasis. But if it gets down to common bile duct than it can also cause obstructive jaundice. Right upper quadrant pain.

Investigations
ERCP investigation can detect and remove the stone.

Treatment
ERCP and some analgesics for pain, and anti-biotics to prevent further infection

Gallbladder infection is called Cholecystitis and the bile duct infection is called cholangitis

CHOLECYSTITIS
Etiological causes
Any type of obstruction. The most common obstruction is the gallstone (cholelithiasis) but it can also be due to worm or parasite such as clonorchis senensis, ascaris lumbricoides, and fasciola hepatica. This can cause cholecystitis and cholangitis. It can also occur without obstruction which is known as acalculous cholecystitis. TPN sickle cell and Diabetic patients.

Clinical Signs and Symptoms
You will see the same pain as cholelithiasis except much longer and more severe. Whereas cholithiasis it is two hours, cholecystitis is 6 hours. There will also be a fever (no rigors) leukocytosis. Gallbladder mass which is generally a late finding and it is associated with jaundice found in less than 10 percent of cases. Murphy's Sign - increase tenderness as they are inspiring

Investigations
CBC - leukocytosis
Amylase to rule out acute pancreatitis, but only greater than 1000IU is significant
Ultrasound you will find thickened gallbladder wall, pericholecystic fluid of bile sludge.
X-ray - radioopaque stone, rule out pneumonia,
CT - perforation and empyema

Treatment
Conservative treatment - IV analgesics anti-biotics
Also give bowel rest by giving NPO
Surgery - laparoscopic cholecystectomy
CHOLANGITIS
Infection of bile duct or inflammation of bile duct.
Caused by obstruction from choledecholithiasis or stricture, pancreatitis.

CLINICAL
Charcot's Triad - Right Upper Quadrant Pain, Fever and Jaundice
Reynold's Pentad - Hypotension, Altered Mental status

INVESTIGATIONS
Ultrasound shows dilated bile ducts
ERCP - see the stones and remove them
Laboratory - leukocytosis, bile duct, Raised ALP, Raised Amylase, High bilirubin

TREATMENT
Acute treatment of cholangitis - IV Fluids, Analgesics and Anti-Biotics. Monitor hemodynamics
Definitive Treatment - 48 hours of being afebrile. ERCP