Biliary Colic and Cholecystitis

Introduction

Gallstones are prevalent in the western population (10-14% will develop gallstones), yet most will remain asymptomatic throughout their life. Each year between 1-4% will develop symptoms secondary to their gallstones.

Pathophysiology

Fig 1 - The biliary system, which transports bile from the gallbladder to the duodenum.

Fig 1 – The biliary system, which transports bile from the gallbladder to the duodenum.

Bile is formed from cholesterol, phospholipids, and bile pigments (products of haemoglobin metabolism). It is stored in the gallbladder, before passing into the duodenum upon gallbladder stimulation. Gallstones form as a result of supersaturation of the bile.

There are three main types of gallstones:

  • Cholesterol stones – composed purely of cholesterol, from excess cholesterol production.
    • There is a well recognised link between poor diet, obesity and cholesterol stones.
  • Pigment stones – composed purely of bile pigments, from excess bile pigments production.
    • May be caused by a haemolytic anaemia.
  • Mixed stones – comprised of both cholesterol and bile pigments.

Risk Factors

Classically the common risk factors for gallstone disease are described as the 5 F’s of Fat, Female, Fertile, Forty, and Family history.

Other recognised risk factors include pregnancy and oral contraceptives*, haemolytic anaemia, and malabsorption (e.g. ileal resection or Crohn’s disease).

*Oestrogen causes more cholesterol to be secreted into bile


Clinical Features

Studies have shown for those who are symptomatic, over 50% will present as biliary colic and 35% as an acute cholecystitis

Asymptomatic

Gallstones can be picked up incidentally on scans, most commonly a trans-abdominal ultrasound scan.

Fig 2 - Gallstone found incidentally on US scan in an asymptomatic patient

Fig 2 – Gallstone found incidentally on US scan in an asymptomatic patient

Biliary Colic

Biliary colic occurs when the gallbladder neck becomes impacted by a gallstone. There is no inflammatory response, yet the contraction of the gallbladder against the occluded neck will result in pain.

The pain is typically sudden, dull, and colicky (comes and goes) in nature. It is often focused in the right upper quadrant although it may radiate to the epigastrium and/or back. The pain may be precipitated by the consumption of fatty foods* and the patient often complains of nausea and vomiting. In general, once pain relief has been started, symptoms often settle quickly.

*Fatty acids stimulate the duodenum endocrine cells to release cholecystokinin (CCK), which in turn stimulates contraction of the gallbladder.

Acute Cholecystitis

The symptoms of acute cholecystitis are often similar to that of someone with biliary colic, although the pain may be constant, more persistent (despite pain relief), and is often associated with signs of inflammation (e.g fever, or raised WCC). The patient may also demonstrate some derangement of their liver function tests.

Patients with acute cholecystitis are likely to demonstrate a positive Murphy’s sign.

When examining any patient with suspected gallbladder pathology, it is important to check for signs of inflammation (raised heart rate, pyrexia), signs of peritonitis or perforation, and signs of jaundice or hepatomegaly.

Murphy’s Sign

Whilst applying pressure in the RUQ, ask the patient to inspire. Murphy’s sign is positive when there is a halt in inspiration due to pain, indicating an inflamed gallbladder. This can be achieved more accurately with an ultrasound, namely the sonographic Murphy sign.


Differential Diagnosis

There are a wide variety of pathologies that can present with RUQ pain. However, differentials to consider for any suspected gallbladder disease include gastro-oesophageal reflux disease, peptic ulcer disease, acute pancreatitis, or inflammatory bowel disease.

Don’t forget about primary hepatic causes of pain and muscular-skeletal issues for example rib fractures.


Investigations

Laboratory Test

Urinalysis (including a pregnancy test if female) should be performed to exclude any renal and tubo-ovarian pathology. Routine blood tests should be ordered:

  • FBC and CRP – assess for the presence of any inflammatory response.
  • U&Es – assess for any dehydration, as a patient with biliary colic or acute cholecystitis may have had reduced oral fluid intake (as certain foods can worsen the pain).
  • LFTs – biliary colic and acute cholecystitis are likely to show a raised ALP (indicating ductal occlusion), yet the other parameters should remain within normal ranges.
  • Amylase – to check for pancreatitis.

Imaging

Trans-abdominal ultrasound is one of the most sensitive modality for visualising gallstone disease, and is typically used first line to investigate suspected gallstone pathology (yet a sensitivity around 50%). Three specific areas are often visualised on US:

  • The presence of gallstones or sludge (the start of gallstone formation).
  • Gallbladder wall thickness (if thick walled, inflammation is likely).
  • Bile duct dilatation (indicate a possible stone or stricture in the distal bile ducts).

If results from US scans are inconclusive, further imaging options are available, much to the discretion of the surgeon and radiologist.

A CT scan (either conventional CT or CT cholangiography) can identify gallstones to a higher sensitivity than US, showing potential attenuation changes around any gallstone in the biliary tree.

The gold standard investigation for gallstones is Magnetic Resonance Cholangiopancreatography (MRCP), largely replacing ERCP for diagnostic purposes. MRCP can show potential defects in the biliary tree caused by gallstone disease, with a sensitivity approaching 100%. Any patient with symptoms suggestive of gallstones with inconclusive US or CT scans should undergo a MRCP.

Fig 3 - MRCP image showing stones in the distal common bile duct: (a) Gallbladder with stones (b) Stone in bile duct (c) Pancreatic duct (d) Duodenum.

Fig 3 – MRCP image showing stones in the distal common bile duct: (a) Gallbladder with stones (b) Stone in bile duct (c) Pancreatic duct (d) Duodenum.


Management

Biliary Colic

Initial Management
Patients with biliary colic should be prescribed analgesia, typically non steroidals for example diclofenac and parental opioids (such as morphine), along with an appropriate antiemetic. If there is no improvement in symptoms with analgesia, consider a potential cholecystitis picture.

The patient should be advised about lifestyle factors that may help control symptoms (and help with future surgery), such as a low fat diet, weight loss, increasing exercise, and provided with any PRN analgesia at discharge.

Definitive Management
Following first presentation of biliary colic, there is a high chance of symptom recurrence or the development of complications of gallstones for example cholecystitis, or acute pancreatitis. As a consequence, an elective cholecystectomy is warranted (or a surgical clinic review for consideration for a cholecystectomy) and should ideally be offered within 6 weeks of first presentation. The laparoscopic route is preferred for cholecystectomy but is not always possible.

For those not fit enough for surgery, Ursodeoxycholic acid can be tried – however it is thought that this is not beneficial if gallstones have already formed.

Fig 4 - Images from a laparoscopic cholecystectomy.

Fig 4 – Images from a laparoscopic cholecystectomy.

Acute Cholecystitis

Initial Management
Patients with acute cholecystitis should be started on appropriate antibiotics (such as IV Co-Amoxiclav and Metronidazole) and fluid resuscitation therapy. If the patient demonstrates signs of  sepsis, remember to also start the “sepsis-6 pathway”, as described here.

Ideally, an NG tube should be placed (especially if the patient is vomiting) and the patient made nil by mouth (NBM). Remember that an ultrasound is more sensitive in the absence (or reduction) of bowel gas.

Concurrent analgesia, typically diclofenac and parental opioids, and antiemetics should be prescribed.

Definitive Management
A laparoscopic cholecystectomy is indicated within 1 week, as per NICE guidelines, however this ideally should be done within 72hr of presentation*. A Cochrane review previously demonstrated that earlier cholecystectomies are safe and reduce overall hospital stay however, in many centres this is not currently practical.

*A laparoscopic cholecystectomy after a couple of days of inflammation tends to be a more difficult procedure. 

For those not fit for surgery and not responding to antibiotics, a percutaneous cholecystotomy can be performed with the patient advised regarding a low fat diet.

Complications of Cholecystectomy

The main complications related to cholecystectomies are:

  • Infection
  • Bile leak
  • Bile duct injury
  • Retained common bile duct stone
    • In a patient readmitted with RUQ pain post-cholecystectomy, it is important to exclude a retained CBD stone post operatively via LFTs and USS.
  • Gallbladder bed haematoma
  • Injury to the bowel or blood vessels


Complications

Gallbladder Empyema

A gallbladder empyema is when the gallbladder is infected and an abscess forms within it. Patients are typically markedly septic, however presenting with a similar-type picture to acute cholecystitis, and has a significant morbidity and mortality.

The condition is diagnosed by either US or CT scan. Treatment is still via laparoscopic cholecystectomy* (may require intra-operative drainage if tense gallbladder) or percutaneous cholecystostomy (if unsuitable for surgery).

*There is a higher rate of conversion to open cholecystectomy with emypema than uncomplicated acute cholecystitis

Chronic Cholecystitis

Patients will typically have a history of recurrent or untreated cholecystitis, which has lead to the chronic inflammation of the gallbladder wall. It may be asymptomatic or present with ongoing RUQ or epigastric pain with associated nausea and vomiting.

It can be diagnosed typically by CT scan. Management in uncomplicated cases is via elective cholecystectomy. Its main complications are increased risk of gallbladder carcinoma and a biliary-enteric fistula.

Bouveret’s Syndrome and Gallstone Ileus

Inflammation of the gallbladder (typically if recurrent or silent) can cause a fistula to form between the gallbladder wall and the duodenum, allowing gallstones to pass into the small bowel. As a consequence, bowel obstruction can occur:

  • Bouveret’s Syndrome  stone impacts to cause duodenal obstruction.
  • Gallstone Ileus stone impacts to cause an obstruction at the terminal ileum (the the narrowest part of the adult bowel).
    *The term ileus is misleading, as it is actually an obstruction

Other complications include obstructive jaundice, ascending cholangitis, and acute pancreatitis.

Further Reading

Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis
Keus F et al., Cochrane Review

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