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Gallbladder

Gallbladder Disease

Overview

Cholesterol gallstones (85%) are the most common

• Risk factors: Four Fs (female, fertile, fat, and forty)

• Due to imbalance between bile, lecithin, and cholesterol

Pigmented stones (15%)

• Risk factors: Hemolytic disorders, biliary tract infection, ileal resection, cirrhosis

Definitions

Acute cholecystitis—inflammation of the gallbladder from stone impaction in the cystic duct

Choledocholithiasis—gallstone in the common bile duct which may lead to cholangitis

Signs and Symptoms

Acute cholecystitis—leukocytosis and right upper quadrant pain

• Murphy’s sign: Deep palpation of the liver edge during inspiratory phase worsens the pain, causing patient to cease inspiration

Choledocholithiasis/ascending cholangitis

• Charcot’s triad: Fever, jaundice, and right upper quadrant pain

• Reynold’s pentad: Charcot’s triad + altered mental status + shock

Diagnosis

Ultrasound is the test of choice with high sensitivity and specificity

• Acute cholecystitis

Gallbladder wall thickening (greater than 3 mm), gallbladder distension (greater than 10 × 4 cm), pericholecystic fluid, gallstone impacted in the cystic duct, and sonographic Murphy’s sign (Murphy’s sign pressing the ultrasound probe over the visualized gallbladder).

Evaluate common bile duct size to determine if there is dilatation and/or choledocholithiasis

• HIDA scan can be helpful if findings are not definitive on ultrasound

Non-visualization of the gallbladder even after administering morphine (which closes the Sphincter of Oddi)

Treatment

Symptomatic cholelithiasis, biliary dyskinesia—elective laparoscopic cholecystectomy

Acute cholecystitis—antibiotics, laparoscopic cholecystectomy

• Percutaneous cholecystostomy tube for ICU patients or patients who cannot tolerate surgery

Choledocholithiasis, ascending cholangitis—endoscopic retrograde cholangiopancreatography (ERCP)

• Percutaneous transhepatic tube placement if ERCP is not available or if patient’s anatomy does not allow for ERCP

Indications for intraoperative cholangiogram

• Previous history of choledocholithiasis, elevated liver function tests, gallstone pancreatitis

• Ultrasound showing dilated biliary duct

• Uncertainty of the anatomy during cholecystectomy

Other Important Facts

Gallbladder wall calcification (porcelain gallbladder)—Perform cholecystectomy due to increased risk of gallbladder cancer

Gallbladder polyp—Perform cholecystectomy for patients who are symptomatic, polyps >1 cm, in patients greater than 50 years old, fast-growing/sessile polyps

Be mindful of gallbladder adenocarcinoma presenting acutely. Look for signs of an invasive gallbladder fossa mass, liver invasion or metastases, and lymphadenopathy.

RADIOLOGY

Acute Cholecystitis

US findings (Fig. 4.1)

• Gallbladder distention with dimensions greater than 10 × 4 cm

• Pericholecystic fluid

• Gallbladder wall thickening greater than 3 mm

• Positive sonographic Murphy’s sign (the most specific finding)

CT findings

• Gallbladder wall thickening and distention

• Pericholecystic fluid

• Fat stranding around gallbladder

• Gallstones are seen in minority of cases as either high- or low- density masses

HIDA findings

• Nonvisualization of gallbladder resulting from cystic duct obstruction

• Imaging performed 2 to 4 hours after administration of tracer, sometimes with the administration of morphine (which closes the Sphincter of Oddi to improve sensitivity)

FIGURE 4.1 A,B