Cholelithiasis and related disorders
Cholelithiasis and related disorders: Excerpt from Professional Guide to Diseases (Eighth Edition)
Diseases of the gallbladder and biliary tract are common and, in many cases, painful conditions that usually require surgery and may be life-threatening. They are generally associated with deposition of calculi and inflammation. (See Common sites of calculi formation, page 766.)
Causes and incidence
Cholelithiasis, 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 due to pregnancy, hormonal contraceptives, diabetes mellitus, celiac disease, cirrhosis of the liver, and pancreatitis. Cholelithiasis is a common health problem, affecting about 1 out of every 1,000 people. The prognosis is usually good with treatment unless infection occurs, in which case the prognosis depends on its severity and response to antibiotics.
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. Prognosis is good unless infection occurs.
Cholangitis, infection of the bile duct, is commonly associated with choledocholithiasis and may follow percutaneous transhepatic cholangiography or occlusion of endoscopic stents. Predisposing factors may 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.
Cholecystitis, acute or chronic inflammation of the gallbladder, is usually associated with a gallstone impacted in the cystic duct, causing painful distention of the gallbladder. Cholecystitis accounts for 10% to 25% of all patients requiring gallbladder surgery. The acute form is most common during middle age; the chronic form usually occurs among elderly patients. The prognosis is good with treatment.
Cholesterolosis, polyps or crystal deposits of cholesterol 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 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.
Biliary cirrhosis, ascending infection of the biliary system, sometimes follows viral destruction of liver and duct cells, but the primary cause is unknown. This condition usually leads to obstructive jaundice and involves the portal and periportal spaces of the liver. It’s nine times more common among women ages 40 to 60 than among men. The prognosis is poor without liver transplantation.
Gallstone ileus results from a gallstone lodging at the terminal ileum; it’s more common in the elderly. The prognosis is good with surgery.
Postcholecystectomy syndrome commonly results from residual gallstones or stricture of the common bile duct. 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.
Acalculous cholecystitis is more common in critically ill patients, accounting for about 5% of cholecystitis cases. It may result from primary infection with such organisms as Salmonella typhi, Escherichia coli, or Clostridium or from obstruction of the cystic duct due to lymphadenopathy or a tumor. It appears that ischemia, usually related to a low cardiac output, also has a role in the pathophysiology of this disease. Signs and symptoms of acalculous cholecystitis include unexplained sepsis, right upper quadrant pain, fever, leukocytosis, and a palpable gallbladder.
Each of these disorders produces its own set of complications. Cholelithiasis may lead to any of the disorders associated with gallstone formation: cholangitis, cholecystitis, choledocholithiasis, and 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.
In most cases, gallbladder and bile duct diseases occur in people who are older than age 40 and are more prevalent in women and Native Americans.
Signs and symptoms
Although gallbladder disease may produce no symptoms, acute cholelithiasis, acute cholecystitis, choledocholithiasis, and cholesterolosis produce the symptoms of a classic gallbladder attack. Attacks usually follow meals rich in fats or may occur at night, suddenly awakening the patient. They 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 department care. Other features may 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 stools (with choledocholithiasis).
Clinical features 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 symptom is intermittent recurrence of colicky pain over several days.
Diagnosis
Echography and X-rays detect gallstones. Other tests may include the following:
❑ Abdominal computed tomography scan or ultrasound reflects stones in the gallbladder.
❑ Percutaneous transhepatic cholangiography, done under fluoroscopic control, distinguishes 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.
❑ HIDA scan of the gallbladder detects obstruction of the cystic duct.
❑ Oral cholecystography shows stones in the gallbladder and biliary duct obstruction.
An elevated icteric index and total bilirubin, urine bilirubin, and alkaline phosphatase levels support the diagnosis. The 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 distinguish gallbladder disease from pancreatitis. With suspected heart disease, serial cardiac enzyme tests and electrocardiography should precede gallbladder and upper GI diagnostic tests.
Treatment
Surgery, usually elective, is the treatment of choice for gallbladder and bile duct diseases and may include open or laparoscopic cholecystectomy, cholecystectomy with operative cholangiography, and possibly exploration of the common bile duct. Electrohydraulic shock wave lithotripsy can be used to fragment gallstones if they’re few in number; it may be used with ursodeoxycholic acid to improve dissolution. Other treatments include a low-fat diet to prevent attacks and vitamin K for itching, jaundice, and bleeding tendencies due to vitamin K deficiency. Treatment during an acute attack may include insertion of a nasogastric tube and an I.V. line and, possibly, antibiotic administration.
A nonsurgical treatment for choledocholithiasis involves placement of a catheter through the percutaneous transhepatic cholangiographic route. Guided by fluoroscopy, the catheter is directed toward the stone. A basket is threaded through the catheter, opened, twirled to entrap the stone, closed, and withdrawn. This procedure can be performed endoscopically.
Chenodeoxycholic acid, which dissolves radiolucent stones, provides an alternative for patients who are poor surgical risks or who refuse surgery.
Special considerations
Patient care for gallbladder and bile duct diseases focuses on supportive care and close postoperative observation.
❑ 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 procedures that will be performed before, during, and after surgery to help ease the patient’s anxiety and to help ensure his cooperation.
❑ After surgery, monitor the patient’s vital signs for signs of bleeding, infection, or atelectasis.
❑ Evaluate the incision site for bleeding. Serosanguineous drainage is common during the first 24 to 48 hours if the patient has a wound drain. If, after a choledochostomy, a T-tube drain is placed in the duct and attached to a drainage bag, make sure that the drainage tube has no kinks. Also check that the connecting tubing from the T tube is well secured to the patient to prevent dislodgment.
❑ Measure and record T-tube drainage daily (200 to 300 ml is normal).
❑ Teach patients who will be discharged with a T tube how to perform dressing changes and routine skin care.
❑ Monitor the patient’s intake and output. Allow him nothing by mouth for 24 to 48 hours or until bowel sounds return and nausea and vomiting cease (postoperative nausea may indicate a full bladder).
❑ If the patient doesn’t void within 8 hours (or if the amount voided is inadequate based on I.V. fluid intake), percuss over the symphysis pubis for bladder distention (especially in the patient receiving anticholinergics). The patient who has had a laparoscopic cholecystectomy may be discharged the same day or within 24 hours after surgery. He 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 few days to a week.
❑ Encourage deep-breathing and leg exercises every hour. The patient should ambulate after surgery. Provide elastic stockings to support the leg muscles and promote venous blood flow, thus preventing stasis and clot formation.
❑ Evaluate the location, duration, and character of any pain. Administer adequate medication to relieve pain, especially before such activities as deep breathing and ambulation, which increase pain.
❑ At discharge, advise the patient against heavy lifting or straining for 6 weeks. Urge him to walk daily. Tell him 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.
❑ Instruct the patient to notify the surgeon if he has pain for more than 24 hours or notices any jaundice, anorexia, nausea or vomiting, fever, or tenderness in the abdominal area because these may indicate a biliary tract injury from cholestectomy, requiring immediate attention.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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