Cholelithiasis or Gallstones

Gall stones are hardened deposits of digestive fluid that can form in your gallbladder. The gallbladder is a small organ located just beneath the liver. The gallbladder holds a digestive fluid known as bile that is released into your small intestine

Biliary colic is usually caused by the gallbladder contracting in response to some form of stimulation, forcing a stone through the gallbladder into the cystic duct opening, leading to increased gallbladder wall tension and pressure which often result in pain known as biliary colic. As the gallbladder relaxes, the stones often fall back into the gallbladder, and the pain subsides within 30 to 90 minutes.

Fatty meals are a common trigger for gallbladder contraction. The pain usually starts within an hour after a fatty meal and is often described as intense and dull, and may last from 1 to 5 hours. However, an association with meals is not universal, and in a significant proportion of patients, the pain is nocturnal. The frequency of recurrent episodes is variable, though most patients do not have symptoms on a daily basis.

A thorough physical exam is useful to distinguish biliary pain due to acute cholecystitis, uncomplicated cholelithiasis or other complications.

In uncomplicated biliary colic, the patient is afebrile and has an essentially benign abdominal examination without rebound or guarding.

Acute Pancreatitis

Appendicitis

Bile Duct Strictures

Bile Duct Tumors

Diabetic ketoacidosis

Emergent Treatment of Gastroenteritis

Esophageal spasm

Gallbladder Cancer

Gastroesophageal reflux disease (GERD)

Hepatitis

Irritable bowel syndrome

Pancreatic Cancer

Pancreatitis (acute or chronic)

Peptic Ulcer Disease

Management

Management of gallstones can be divided into two categories: asymptomatic gallstones and symptomatic gallstones.

Asymptomatic gallstones require the patient to be counseled regarding symptoms of biliary colic and when to seek medical attention. Cholelithiasis without complications can be treated acutely with oral or parenteral analgesia in the emergency department or urgent care center once the diagnosis has been established and alternative diagnoses excluded. Patients should also be offered dietary advice to reduce the chance of recurrent episodes and referred to a general surgeon for elective laparoscopic cholecystectomy. Today, laparoscopic cholecystectomy is the standard of care and most patients are managed as outpatients.

Patients with symptoms and workup consistent with acute cholecystitis will require admission to hospital, surgical consult and intravenous antibiotics. Patients with choledocholithiasis or gallstone pancreatitis will also require admission to hospital, gastrointestinal (GI) consultation and ERCP or MRCP. Patients with acute ascending cholangitis are usually ill-appearing and septic. They often also require aggressive resuscitation and ICU-level care in addition to surgical intervention to drain an infection in the biliary tract.

Medical treatment with ursodeoxycholic acid is an option but not practical. The patient must have stones less than 1 cm with high cholesterol content. But the therapy can take 9-12 months to dissolve the stone in only 50% of cases.

Extracorporeal shockwave lithotripsy for non-calcified gallstones is another option.