Cholelithiasis, cholecystitis, and related disorders
Cholelithiasis, cholecystitis, and related disorders: Excerpt from Handbook of Diseases
Diseases of the gallbladder and biliary tract are common, typically painful conditions that usually require surgery and may be life-threatening. They’re commonly associated with deposition of calculi and inflammation. (See Common sites of calculus formation.)
In most cases, gallbladder and bile duct diseases occur during middle age. Between ages 20 and 50, they’re six times more common in women, but the incidence in men and women becomes equal after age 50. After that, incidence rises with each succeeding decade.
Causes
The origin and frequency of gallbladder and biliary tract disease vary with the particular disorder.
Cholelithiasis
The presence of stones or calculi (gallstones) in the gallbladder results from changes in bile components. Gallstones are made of cholesterol, calcium bilirubinate, or a mixture of cholesterol and bilirubin pigment. They arise during periods of sluggishness in the gallbladder resulting from pregnancy, use of oral contraceptives, diabetes mellitus, Crohn’s disease, cirrhosis of the liver, pancreatitis, obesity, and rapid weight loss.
Cholelithiasis is the fifth leading cause of hospitalization among adults and accounts for 90% of all gallbladder and duct diseases. The prognosis is usually good with treatment unless infection occurs, in which case the prognosis depends on the infection’s severity and response to antibiotics.
Cholecystitis
Cholecystitis, an acute or chronic inflammation of the gallbladder, is usually associated with a gallstone impacted in the cystic duct; the inflammation develops behind the obstruction. Cholecystitis accounts for 10% to 25% of all patients requiring gallbladder surgery.
The acute form is most common during middle age; the chronic form, among elderly people. The prognosis is good with treatment.
Biliary cirrhosis
Primary biliary cirrhosis is a chronic, progressive disease of the liver characterized by autoimmune destruction of the intrahepatic bile ducts and cholestasis. This condition usually leads to obstructive jaundice and pruritus and involves the portal and periportal spaces of the liver. It affects women between the ages of 40 and 60 nine times more often than men. The prognosis is poor without liver transplantation.
Cholangitis
An infection of the bile duct, cholangitis is commonly associated with choledocholithiasis and may follow percutaneous transhepatic cholangiography. Predisposing factors include bacterial or metabolic alteration of bile acids. Widespread inflammation may cause fibrosis and stenosis of the common bile duct. The prognosis for this rare condition is poor without stenting or surgery.
Choledocholithiasis
One out of every 10 patients with gallstones develops choledocholithiasis, or gallstones in the common bile duct (sometimes called common duct stones). This occurs when stones passed out of the gallbladder lodge in the hepatic and common bile ducts and obstruct the flow of bile into the duodenum. The prognosis is good unless infection occurs.
Cholesterolosis
Cholesterol polyps or cholesterol crystal deposits in the gallbladder’s submucosa may result from bile secretions containing high concentrations of cholesterol and insufficient bile salts. The polyps may be localized or may speckle the entire gallbladder. Cholesterolosis, the most common pseudotumor, isn’t related to widespread inflammation of the mucosa or lining of the gallbladder. The prognosis is good with surgery.
Gallstone ileus
Gallstone ileus results from a gallstone lodging in the terminal ileum. It’s more common in elderly people. The prognosis is good with surgery.
Postcholecystectomy syndrome
Postcholecystectomy syndrome commonly results from retained or recurrent common bile duct stones, spasm of the sphincter of Oddi, functional bowel disorder, technical errors, or mistaken diagnoses. It occurs in 1% to 5% of all patients whose gallbladders have been surgically removed and may produce right upper quadrant abdominal pain, biliary colic, fatty food intolerance, dyspepsia, and indigestion. The prognosis is good with selected radiologic procedures, endoscopic procedures, or surgery.
Complications
Each disorder produces its own set of complications. Cholelithiasis may lead to any of the disorders associated with gallstone formation: cholangitis, cholecystitis, choledocholithiasis, or gallstone ileus.
Cholecystitis can progress to gallbladder complications, such as empyema, hydrops or mucocele, or gangrene. Gangrene may lead to perforation, resulting in peritonitis, fistula formation, pancreatitis, limy bile, and porcelain gallbladder. Other complications include chronic cholecystitis and cholangitis.
Choledocholithiasis may lead to cholangitis, obstructive jaundice, pancreatitis, and secondary biliary cirrhosis. Cholangitis, especially in the suppurative form, may progress to septic shock and death. Gallstone ileus may cause bowel obstruction, which can lead to intestinal perforation, peritonitis, septicemia, secondary infection, and septic shock.
Signs and symptoms
Although gallbladder disease may produce no symptoms, acute cholelithiasis, acute cholecystitis, choledocholithiasis, and cholesterolosis all produce the symptoms of a classic gallbladder attack. Such attacks commonly follow meals rich in fats or may occur at night, suddenly awakening the patient.
A gallbladder attack may begin with acute abdominal pain in the right upper quadrant that may radiate to the back, between the shoulders, or to the front of the chest. The pain may be so severe that the patient seeks emergency care.
Other signs and symptoms include recurring fat intolerance, biliary colic, belching, flatulence, indigestion, diaphoresis, nausea, vomiting, chills, low-grade fever, jaundice (if a stone obstructs the common bile duct), and clay-colored stool (with choledocholithiasis).
Signs and symptoms of cholangitis include a rise in eosinophils, jaundice, abdominal pain, high fever, and chills. Biliary cirrhosis may produce jaundice, related itching, weakness, fatigue, slight weight loss, and abdominal pain. Gallstone ileus produces signs and symptoms of small-bowel obstruction —nausea, vomiting, abdominal distention, and absent bowel sounds if the bowel is completely obstructed. Its most telling sign is intermittent recurrence of colicky pain over several days.
Diagnosis
Ultrasonography and X-rays detect gallstones. Specific procedures include the following:
❑ Ultrasonography reflects stones in the gallbladder with 96% accuracy.
❑ Percutaneous transhepatic cholangiography allows imaging under fluoroscopic control to help distinguish between gallbladder or bile duct disease and cancer of the pancreatic head in patients with jaundice.
❑ Endoscopic retrograde cholangiopancreatography visualizes the biliary tree after insertion of an endoscope down the esophagus into the duodenum, cannulation of the common bile and pancreatic ducts, and injection of contrast medium.
❑ Hepatobiliary iminodiacetic acid analogue scan of the gallbladder helps detect obstruction of the cystic duct.
❑ Computed tomography scan, although not routinely used, helps distinguish between obstructive and nonobstructive jaundice.
❑ Plain abdominal X-rays identify calcified but not cholesterol stones with 15% accuracy.
❑ Oral cholecystography shows stones in the gallbladder and biliary duct obstruction.
Elevated icteric index and elevated total bilirubin, urine bilirubin, and alkaline phosphatase levels support the diagnosis. White blood cell count is slightly elevated during a cholecystitis attack.
Differential diagnosis is essential because gallbladder disease can mimic other diseases (myocardial infarction, angina, pancreatitis, pancreatic head cancer, pneumonia, peptic ulcer, hiatal hernia, esophagitis, and gastritis). Serum amylase levels help distinguish gallbladder disease from pancreatitis. With suspected heart disease, cardiac enzyme testsand an electrocardiogram should precede gallbladder and upper GI diagnostic tests.
Treatment
Surgery, usually elective, is the treatment of choice for gallbladder and bile duct diseases. Surgery may include open or laparoscopic cholecystectomy, cholecystectomy with operative cholangiography and, possibly, exploration of the common bile duct.
Other treatment includes a low-fat diet to prevent attacks and vitamin K for itching, jaundice, and bleeding tendencies resulting from vitamin K deficiency. Treatment during an acute attack may include insertion of a nasogastric tube and an I.V. line and, possibly, administration of an antibiotic.
A nonsurgical treatment for choledocholithiasis involves insertion of a flexible catheter, formed around a biliary tube (T tube), through a sinus tract into the common bile duct. Guided by fluoroscopy, the catheter is directed toward the stone. A Dormia basket is threaded through the catheter, opened, twirled to entrap the stone, closed, and withdrawn.
Special considerations
❑ Before surgery, teach the patient to deep breathe, cough, expectorate, and perform leg exercises that are necessary after surgery. Also, teach splinting, repositioning, and ambulation techniques. Explain the perioperative procedures to help ease the patient’s anxiety and ensure his cooperation.
❑ After surgery, monitor vital signs for indications of bleeding, infection, or atelectasis.
❑ If a T tube is surgically placed, maintain tube patency and secure placement. Measure and record bile drainage daily (200 to 300 ml is normal).
❑ If your patient will be discharged with a T tube, teach him how to perform dressing changes and routine skin care.
❑ Patients who have had a laparoscopic cholecystectomy may be discharged the same day or within 48 hours after surgery. These patients should have minimal pain, be able to tolerate a regular diet within 24 hours after surgery, and be able to return to normal activity within a week.
❑ Encourage the patient to perform deep-breathing and leg exercises every hour. The patient should ambulate after surgery. Provide antiembolism stockings to support leg muscles and promote venous blood flow to prevent stasis and clot formation.
❑ Assess the location, duration, and character of any pain. Administer an analgesic, as needed, to relieve pain.
❑ At discharge (usually the day of surgery or 1 to 2 days afterward), teach the patient that food restrictions are unnecessary unless he has an intolerance to a specific food or some underlying condition (such as diabetes, atherosclerosis, or obesity) that requires such restriction.
Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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