Cholelithiasis and Cholecystitis

Cholelithiasis - Stone Cold Facts

• Gallstones in gallbladder.
• Types:
  • Cholesterol stones (~80%): Yellowish, radiolucent.

    ⭐ Most common type of gallstone is cholesterol stone (especially in Western countries).

  • Pigment stones (~20%):
    • Black: Ca bilirubinate; hemolysis (e.g., sickle cell), cirrhosis. Often radiopaque.
    • Brown: Ca soaps of unconj. bilirubin; infection, biliary stasis. Often in bile ducts, radiolucent.
• Risk Factors (Cholesterol): 📌 4 F's: Female, Forty (>40y), Fertile (multiparity, OCPs - estrogen ↑, progesterone ↓ motility), Fat (obesity, rapid weight loss). Also: fibrates, Crohn's, TPN.
• Pathogenesis: Supersaturation (cholesterol/bilirubin), nucleation, gallbladder (GB) hypomotility.
• Presentation: Often asymptomatic. Biliary colic: RUQ/epigastric pain <6h, post-fatty meal, radiates to R shoulder/scapula. N/V. oka

Acute Cholecystitis - Gallbladder's Ire

• Definition: Gallbladder inflammation, usually from cystic duct stone.
• Pathophysiology: Obstruction → Stasis → Chemical/Bacterial inflammation.
• Clinical Features: RUQ pain >6 hrs, fever, +ve Murphy's sign.
• Diagnosis:
  • USG: Wall thickening >3 mm, pericholecystic fluid, sonographic Murphy's.

  ⭐ Sonographic Murphy's sign is highly specific for acute cholecystitis.

  • HIDA scan: Non-visualization (if USG unclear).
  • Tokyo Guidelines: A (local) + B (systemic) + C (imaging) = Definite.
• Management:
  • NPO, IVF, antibiotics.
  • Early Lap Cholecystectomy (within 72 hrs).
• Complications: Gangrene, perforation, empyema.

Gallstone Complications & Chronic Cholecystitis - Trouble Brewing

• Acute Cholangitis: Infection of biliary tree.

  ⭐ Charcot's triad (fever, RUQ pain, jaundice) is indicative of acute cholangitis.

  • 📌 Reynold's pentad: Charcot's triad + hypotension, altered mental status (severe).
  • Tx: IV antibiotics, biliary drainage (ERCP/PTC).
• Gallstone Pancreatitis: Stone obstructs ampulla of Vater. ↑ Amylase/lipase >3x ULN. Tx: Supportive, ERCP if needed.
• Gallstone Ileus: Large stone erodes into bowel (cholecystoenteric fistula), obstructs ileocecal valve.
  • Rigler's triad (X-ray): pneumobilia, small bowel obstruction (SBO), ectopic stone.
• Mirizzi Syndrome: Stone in cystic duct/Hartmann's pouch compresses common hepatic duct (CHD) → jaundice.
• Choledocholithiasis: Stones in common bile duct (CBD).
• Chronic Cholecystitis: Results from recurrent acute attacks or chronic irritation.
  • Symptoms: Vague RUQ pain, dyspepsia, fat intolerance.
  • Pathology: Thickened, fibrotic gallbladder wall; chronic inflammation.
  • Complications: Porcelain gallbladder (calcified wall, ↑ cancer risk), hydrops/mucocele, empyema, gallbladder cancer.

Gallstone Disease: Dx & Rx - See & Solve

• Diagnosis (Dx):
  • Initial: Ultrasound (USG) - detects stones, wall thickness, CBD diameter (>6mm is dilated).

    ⭐ Ultrasound is the initial investigation of choice for suspected gallstone disease.

  • Further (if unclear/complications):
    • MRCP: Best for CBD stones.
    • HIDA scan: For acalculous cholecystitis, cystic duct patency.
    • CT scan: For complications (perforation, pancreatitis).
• Treatment (Rx) Overview:
  • Asymptomatic: Observe (unless high-risk: porcelain GB, stones >3cm).
  • Symptomatic (Biliary Colic): Elective Lap Chole.
  • Acute Cholecystitis: IV fluids, antibiotics, analgesia. Early Lap Chole (within 72h-7d).
    • If unfit/late: Percutaneous cholecystostomy or delayed Lap Chole.
  • Choledocholithiasis: ERCP + stone extraction, then Lap Chole.
  • Gallstone Pancreatitis: Supportive care, ERCP if severe/cholangitis, then Lap Chole.

High‑Yield Points - ⚡ Biggest Takeaways

• Cholesterol stones are the most common type of gallstones.
• Biliary colic is characterized by intermittent RUQ pain, often postprandial.
• Acute cholecystitis presents with constant RUQ pain, fever, and a positive Murphy's sign.
• Ultrasound is the initial imaging modality of choice for gallstones and cholecystitis.
• HIDA scan is the most specific test for acute cholecystitis if ultrasound is equivocal.
• Laparoscopic cholecystectomy is the definitive treatment for symptomatic cholelithiasis and acute cholecystitis.
• Charcot's triad (fever, RUQ pain, jaundice) suggests cholangitis; Reynolds' pentad adds hypotension and altered mental status indicating severe sepsis.