Biliary Tract Disease: Biliary Tract Disease: Stones and Cholecystitis

0:00Welcome to Board Pearls. This is episode one of four of the Biliary Tract Disease chapter, in the Pancreatic and Biliary Disease module. This episode is gallstones and acute cholecystitis. The first patient is a woman whose attacks of pain come and go, and her case shows how biliary colic is recognized, which of her symptoms the stones actually cause, who needs a cholecystectomy, and why she formed stones in the first place. A man with stones found by chance shows who keeps a gallbladder full of stones and who doesn't. The second patient is a woman whose pain won't settle, and her case shows how acute cholecystitis is diagnosed, how it's graded, and how the grade decides between surgery now and surgery later. And a frail man shows how the gallbladder is drained in a patient who can't have an operation.

0:47Here's the first patient. A thirty-seven-year-old Mexican-American woman has had four episodes of severe right upper abdominal pain over three months, each starting an hour after a fatty meal, lasting about two hours, and spreading to her right shoulder blade. Between episodes she feels well, apart from bloating and belching after most meals for years. She has four children, a body mass index of thirty-three, and takes an oral contraceptive. Her ultrasound shows several gallstones, a normal gallbladder wall, and a normal common bile duct.

1:18She has symptomatic gallstones causing biliary colic. Biliary colic is severe epigastric or right upper quadrant pain lasting thirty minutes to several hours, often radiating to the right shoulder or scapula, with pain-free intervals of days to months. It often follows a fatty meal, because cholecystokinin contracts the gallbladder against a stone that transiently blocks the cystic duct, but it can also come at night. Each of her attacks has these features, and the ultrasound supplies the stones. The rest of the ultrasound matters just as much: a normal wall means no cholecystitis, and a normal duct gives no sign of a stone in the common bile duct. So this is uncomplicated colic, and the decisions that follow are what to tell her about her other symptoms and whether her gallbladder should come out.

2:06Her bloating and belching come first, because they change what she's promised. Biliary colic is the only symptom clearly caused by gallstones. Dyspepsia that coexists with stones isn't caused by them: prospective studies show that dyspeptic complaints are unrelated to stones, and the old figure of seventy-five percent relief of dyspepsia after cholecystectomy largely reflects placebo. So she's told that surgery should stop her attacks but may not change her bloating and belching.

2:35Her gallbladder should come out, because once stones cause symptoms they tend to keep doing so. After a first episode of colic, only thirty percent of patients stay symptom-free over long follow-up, and severe complications occur at about one percent a year. Those numbers favor surgery in a fit patient, so she's referred for laparoscopic cholecystectomy without waiting for another attack.

2:57Why she formed stones still matters, for two reasons: it shows which risks belong to her, and an unusual stone type would point to an underlying disease. About seventy-five percent of stones in Western populations are cholesterol stones, fifty to one hundred percent cholesterol, yellow-brown and crystalline, and lucent on plain film in eighty-five percent. They form through three steps. Bile becomes supersaturated, with too much cholesterol or too few bile salts or phospholipids to hold it in solution. A sluggish gallbladder lengthens the time bile sits in contact with crystals. And nucleation starts on mucin, bacteria, calcium-ceftriaxone crystals, or proteins.

3:42Each of her risks acts on that pathway. Estrogen, from her contraceptive and from four pregnancies, raises hepatic cholesterol secretion, and progesterone lowers bile salt synthesis and slows gallbladder emptying. Obesity raises supersaturation, as do hyperlipidemia, diabetes, and Native American or Hispanic ancestry. Pima and other Native American and Mexican-American populations have the world's highest prevalence, approaching fifty to sixty percent in adult Pima women. The five Fs, female, forty, fertile, fat, and fair, summarize the demographic risks, and she has most of them plus her ancestry. Without hemolysis, cirrhosis, or ileal disease, her stones are cholesterol stones.

4:28Other patients form cholesterol stones through the same three steps by different means. A gallbladder that doesn't contract stagnates: rapid weight loss after bariatric surgery or a very-low-calorie diet, and total parenteral nutrition, TPN, remove the post-meal cholecystokinin signal; vagotomy and diabetic autonomic neuropathy remove vagal contraction; and octreotide and somatostatinoma inhibit contraction directly. Ileal disease or resection, and fibrates, shrink the bile salt pool. Inherited variants change the bile itself: ABCB4 mutations reduce biliary phospholipid, CYP7A1 mutations reduce bile acid synthesis, and ABCG5 and G8 variants alter sterol transport. And ceftriaxone seeds stones as calcium-ceftriaxone crystals.

5:21The two pigment stones are the ones that send the search toward another disease. Black pigment stones are hard calcium bilirubinate with calcium phosphate, opaque on film in more than half, and they form when more unconjugated bilirubin reaches the gallbladder than bile can dissolve. The causes are chronic hemolysis, such as sickle cell disease; shear hemolysis from mechanical valves, transcatheter aortic valve replacement, or left ventricular assist devices; and Gilbert syndrome, cirrhosis, cystic fibrosis, and Crohn disease. So black stones prompt a search for hemolysis or cirrhosis. Brown pigment stones are soft, greasy, and lucent, and they form in the bile duct when bacterial beta-glucuronidase deconjugates bilirubin in infection or stasis. They go with strictures, duodenal diverticula, post-sphincterotomy anatomy, and parasites, and they're the most common stone found more than two years after cholecystectomy. So a duct stone found years after surgery is usually a new brown stone, not a retained one.

6:24Her symptoms made surgery the answer, and a man without symptoms shows why the same stones usually aren't operated on. A sixty-one-year-old man's computed tomography, CT, for kidney stones showed several small gallstones, and he's never had pain. About ten percent of adults in the United States have gallstones, and seventy-five percent never have symptoms. Asymptomatic stones progress to symptoms or complications at one to four percent a year, while elective cholecystectomy carries a perioperative mortality of zero point one to three percent in the average-risk patient, so asymptomatic stones are observed. He's taught what biliary colic feels like, so he'd recognize the symptom that changes the decision.

7:05Some asymptomatic patients still need their gallbladder out, because their cancer risk is high enough to outweigh the operation. A porcelain gallbladder with mucosal or incomplete calcification is one, because patchy calcification preserves mucosa where dysplasia can progress, while complete circumferential calcification may be observed in selected patients. Stones of three centimeters or more carry about ten times the cancer risk of stones under one centimeter. Polyps alongside stones combine the polyp's neoplastic risk with the risk from inflammation. Native American women with gallstones, especially Pima women, have a baseline gallbladder cancer risk among the highest in the world. Pancreaticobiliary maljunction with a biliary cyst, highest with Todani types one and four, calls for cholecystectomy as part of the cyst excision. And a polyp of one centimeter or more, or over eight millimeters in primary sclerosing cholangitis, and chronic Salmonella typhi carriage are indications too.

8:03Other asymptomatic patients have their gallbladder removed because of the setting they're in. In hemolytic disorders, cholecystectomy is timed with other planned abdominal surgery. Sickle cell disease with documented stones and evaluation for a heart or lung transplant are indications. And bariatric patients with stones often have the gallbladder removed during the same operation, because the rapid weight loss afterward brings on symptoms. So a single three-and-a-half-centimeter stone would earn him an operation, and dense opaque stones in a man with a mechanical valve would be black pigment stones from shear hemolysis. The porcelain gallbladder is covered in episode two and biliary cysts in episode four.

8:46The second patient's pain is different, because it hasn't stopped. A fifty-four-year-old woman with known gallstones has had right upper quadrant pain for thirty hours that hasn't settled like her previous attacks. Her temperature is thirty-eight point four, and she stops breathing in when pressed under her right ribs. Her white count is fourteen thousand and her C-reactive protein is raised. Her alanine aminotransferase, ALT, is sixty, her alkaline phosphatase is mildly raised, and her bilirubin is one point four. Her blood pressure, kidneys, and mental status are normal.

9:20She has acute cholecystitis. Colic is a stone transiently blocking the cystic duct, so the pain resolves within hours. Cholecystitis is persistent obstruction by an impacted stone: bile becomes increasingly concentrated, mucosal phospholipase releases lysolecithin that inflames the wall, and bacteria superinfect it. That's why the pain lasts beyond the usual few hours and comes with fever, leukocytosis, and a positive Murphy sign, all of which she has; her catch in breathing when pressed under her right ribs is the Murphy sign.

9:52Confirming it takes three elements, because each alone is non-specific. The Tokyo Guidelines twenty eighteen require local signs, a Murphy sign or a right upper quadrant mass, pain, or tenderness; systemic signs, fever, leukocytosis, or a raised C-reactive protein; and confirmatory imaging. Right upper quadrant ultrasound comes first, with a sensitivity of eighty-eight percent and a specificity of eighty. A sonographic Murphy sign has a ninety percent positive predictive value, wall thickening over three point five millimeters and pericholecystic fluid confirm the diagnosis, and distension over four centimeters supports it. Hers shows a stone impacted in the neck, a five-millimeter wall, pericholecystic fluid, and a sonographic Murphy sign, so she meets all three elements.

10:42A hepatobiliary iminodiacetic acid, HIDA, scan is second line, for an equivocal ultrasound, with a sensitivity of ninety-seven percent and a specificity of ninety. A gallbladder that doesn't fill by ninety minutes while the duct and small bowel do is the imaging definition of cystic duct obstruction. HIDA is also the test when acalculous cholecystitis is suspected. She doesn't need one, because her ultrasound is diagnostic.

11:09Her liver tests decide whether anything else is going on. In cholecystitis alone, liver tests are normal or less than twice normal. Marked rises in transaminases or bilirubin point instead to a stone in the common bile duct or to Mirizzi syndrome, a stone in the gallbladder neck or cystic duct compressing the common duct. Her modest values fit cholecystitis alone. An ALT of four hundred and a bilirubin of four would prompt a search for a duct stone before surgery. Mirizzi syndrome is covered in episode two, and duct stones in episode three.

11:43With the diagnosis confirmed and the duct cleared, her Tokyo grade sets how aggressively and when she's treated. Grade one, mild, has no organ dysfunction and no marked local inflammation. Grade two, moderate, has a white count over eighteen thousand, a palpable right upper quadrant mass, symptoms for more than seventy-two hours, or marked local inflammation, such as gangrenous or emphysematous cholecystitis or biliary peritonitis. Grade three, severe, has cardiovascular, neurologic, respiratory, renal, hepatic, or hematologic dysfunction. Her normal blood pressure, kidneys, and mental status exclude grade three, and her white count, thirty-hour course, and ultrasound exclude grade two, so she's grade one. The ultrasound is always read for severity too, because a gangrenous or gas-containing wall makes the disease grade two however well the patient looks.

12:39Each grade has its treatment, and the logic is protecting the bile duct. Grade one gets fluids, antibiotics, and early laparoscopic cholecystectomy in the same admission, within seven days, before the inflammation matures into a dense fibrotic phase that hides Calot's triangle and raises the risk of bile duct injury. She has hers on day two. Grade two gets antibiotics with early cholecystectomy at a high-volume center, or percutaneous cholecystostomy with delayed cholecystectomy. When dense inflammation is already present, a six-week delay lets it settle, so speed in grade one and delay in grade two both protect the duct.

13:18Grade three needs something else, because the patient can't survive an immediate operation. It needs intensive care unit resuscitation and emergent gallbladder drainage, with cholecystectomy deferred until recovery, and in some patients with permanent comorbidity never done. The stakes are real: elective cholecystectomy carries about zero point one percent mortality, while acute cholecystitis carries five to ten percent overall, concentrated in patients over sixty with comorbidities and in those with suppurative complications.

13:50The last decision is how to drain a patient who can't have surgery. An eighty-four-year-old man with severe heart failure and chronic kidney disease has acute cholecystitis, confusion, a systolic pressure of eighty-five despite fluids, and a doubled creatinine. His hypotension, confusion, and kidney injury are organ dysfunction, so he's grade three, and he needs drainage, not an operation.

14:13His drainage method is chosen by what his anatomy allows. The twenty twenty-four American Society for Gastrointestinal Endoscopy guideline on therapeutic endoscopic ultrasound recommends gallbladder drainage with a lumen-apposing metal stent, placed under endoscopic ultrasound, as first line over percutaneous drainage where the expertise exists. The stent creates a permanent internal fistula into the duodenum or stomach, with no external drain to care for or dislodge, and a randomized trial showed higher clinical success and fewer reinterventions. The technique is covered in chapter twenty-nine. The stent is contraindicated by perforation, emphysematous cholecystitis, where the wall is ischemic and friable, uncontrolled coagulopathy, large-volume ascites that separates the gallbladder from the gut wall, and a poor endosonographic window. His heart failure has given him large-volume ascites, so he has a percutaneous cholecystostomy instead. Endoscopic retrograde cholangiopancreatography with a stent placed into the cystic duct is the third-line option when both are impractical.

15:17Here are the traps the boards set in gallstones. Dyspepsia isn't caused by gallstones, and surgery isn't promised to fix it. Asymptomatic stones aren't removed in an average-risk patient. One attack of colic in a fit patient favors surgery. The prophylactic indications are an incompletely calcified porcelain gallbladder, stones of three centimeters or more, a coexisting polyp, maljunction with a cyst, high-risk ethnicity, and a polyp of a centimeter, or eight millimeters in primary sclerosing cholangitis. Ceftriaxone, octreotide, TPN, and rapid weight loss cause stones. And a duct stone found years after cholecystectomy is usually a new brown stone, not a retained one.

15:59For cholecystitis, the traps are these. Local signs alone don't make the diagnosis. Marked liver test rises aren't blamed on cholecystitis before a duct stone and Mirizzi syndrome are looked for. HIDA isn't ordered first when ultrasound is diagnostic. A grade one patient isn't sent home for interval surgery. Dense inflammation is waited out for six weeks rather than operated through. A grade three patient isn't taken straight to surgery. A percutaneous tube isn't chosen over a stent placed under endoscopic ultrasound when the expertise exists. And that stent isn't placed through ascites, a perforation, or an emphysematous gallbladder.

16:39So, start to finish. Biliary colic is episodic pain of thirty minutes to several hours, often after fatty meals, and it's the only symptom stones clearly cause; dyspepsia isn't. Remove the gallbladder after colic in a fit patient, observe asymptomatic stones in most people, and operate on asymptomatic stones only when cancer or emergency risk is high. Cholesterol stones come from supersaturation, stasis, or nucleation, driven by estrogen, obesity, ancestry, and stasis, black pigment stones mean hemolysis, cirrhosis, or ileal disease, and brown stones mean an infected, stagnant duct.

17:17Acute cholecystitis is an impacted cystic duct stone with inflammation and infection, diagnosed by the Tokyo criteria of local signs, systemic signs, and imaging, with ultrasound first and HIDA when it's equivocal. Marked liver test rises mean looking for a duct stone or Mirizzi syndrome. Grade one gets early laparoscopic cholecystectomy within seven days, grade two gets antibiotics with early surgery at an experienced center or drainage with delayed surgery, and grade three gets intensive care and urgent drainage. For poor surgical candidates, a stent placed under endoscopic ultrasound is preferred over a percutaneous tube where expertise exists, except with perforation, emphysematous cholecystitis, coagulopathy, or large ascites.

18:02Episode two is the gallbladder variants and complications: acalculous and emphysematous cholecystitis, Mirizzi syndrome, porcelain gallbladder, gallstone ileus, and polyps and cancer.

18:15For the full chapter, the practice vignettes, and the topic-tagged question bank, head to board pearls dot com. You'll find the rest of the series on Apple Podcasts, Spotify, or wherever you listen to podcasts. That brings us to the end of episode one of four of chapter twenty-seven, and I'll see you in the next one.