Gastroenterology

Disorders of the biliary system:

gallstone diseases

With Kelley Chuang, M.D.

Learning Objectives

In this lecture, you will learn how to...

• distinguish between cholelithiasis and

choledocholithiasis.

• describe the basic management of acute

cholecystitis.

• identify the symptoms of ascending

cholangitis.

• select an appropriate imaging modality to

diagnose a gallbladder disorder based on
the clinical picture.
25-year-old Woman with Right Upper Quadrant Pain Test case

A 25-year-old woman with no known medical history presents Intermittent RUQ pain after
to urgent care with intermittent right upper quadrant (RUQ) eating, lasting minutes
pain. In the past 2 weeks, she has had several episodes of pain consider biliary colic
after eating, which last for a few minutes. Today, she had an
episode of severe RUQ pain with nausea, which resolved after
30 minutes. She takes no medications.
Normal vitals, exam, and
Vitals are normal. Abdominal exam is unremarkable. Lab labs are reassuring against
studies, including a CBC, lipase, and hepatic panel, are normal. acute cholecystitis
Ultrasound of the RUQ shows gallbladder stones without ductal
dilatation. RUQ ultrasound shows
gallstones without evidence
What is the best next step in management? of cholecystitis
Cholelithiasis and Choledocholithiasis

Cholelithiasis
Stone in gallbladder

Choledocholithiasis
Stone in common bile duct

© by Lecturio
Review Gallbladder Terminology
Disease Pathology Hepatic panel Imaging Treatment

Asymptomatic Stone in gallbladder Normal Ultrasound Observation

cholelithiasis without obstruction

Symptomatic Stone in gallbladder, Normal Ultrasound Elective

cholelithiasis intermittent cholecystectomy
obstruction (biliary
colic)

Choledocholithiasis Stone obstructing Cholestatic MRCP or Remove stone

common bile duct pattern Ultrasound with ERCP and
elevation sphincterotomy

ERCP = endoscopic retrograde cholangiopancreatography, MRCP = magnetic resonance cholangiopancreatography

Symptoms of Cholelithiasis

How do patients with cholelithiasis

typically present?
Symptoms of Cholelithiasis

Biliary colic is the acute onset of upper abdominal pain,

usually lasting minutes to several hours, sometimes
accompanied by nausea or vomiting. These episodes are
self-limited and usually occur after eating.
Diagnosis and Management of Cholelithiasis

• May be asymptomatic, or present with biliary Cholelithiasis

colic

• Diagnosis: RUQ ultrasound

• Management:

• Asymptomatic  observation

• Symptomatic  elective cholecystectomy

© by Lecturio
Diagnosis and Management of Cholelithiasis

Types of gallstones:

1. Cholesterol/mixed: associated
with female gender, advanced
age, North/South American
indigenous populations

2. Pigmented: associated with

chronic hemolysis, cirrhosis, or
terminal ileal disease
A: Cholesterol gallstone B: Mixed gallstone C: Pigment gallstone

© 2015 Weerakoon et al, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4390354/figure/pone.0121537.g001/, CC BY 4.0, no changes

25-year-old Woman with Right Upper Quadrant Pain Test case

A 25-year-old woman with no known medical history presents Intermittent RUQ pain after
to urgent care with intermittent right upper quadrant (RUQ) eating, lasting minutes
pain. In the past 2 weeks, she has had several episodes of pain  consider biliary colic
after eating, which last for a few minutes. Today, she had an
episode of severe RUQ pain with nausea, which resolved after
30 minutes. She takes no medications.
Normal vitals, exam, and
Vitals are normal. Abdominal exam is unremarkable. Lab labs are reassuring against
studies, including a CBC, lipase, and hepatic panel, are normal. acute cholecystitis
Ultrasound of the RUQ shows gallbladder stones without ductal
dilatation. RUQ ultrasound shows
gallstones without evidence
What is the best next step in management? of cholecystitis
25-year-old Woman with Right Upper Quadrant Pain Answer
Test case

A 25-year-old woman with no known medical history presents Intermittent RUQ pain after
to urgent care with intermittent right upper quadrant (RUQ) eating, lasting minutes
pain. In the past 2 weeks, she has had several episodes of pain  consider biliary colic
after eating, which last for a few minutes. Today, she had an
episode of severe RUQ pain with nausea, which resolved after
30 minutes. She takes no medications.
Normal vitals, exam, and
Vitals are normal. Abdominal exam is unremarkable. Lab labs are reassuring against
studies, including a CBC, lipase, and hepatic panel, are normal. acute cholecystitis
Ultrasound of the RUQ shows gallbladder stones without ductal
dilatation. RUQ ultrasound shows
gallstones without evidence
Answer: referral for elective cholecystectomy of cholecystitis
31-year-old Man with 2 Days of RUQ Pain Test case

A 31-year-old man with no past medical history presents to the RUQ pain with fever,
ED with 2 days of RUQ pain accompanied by fever, nausea, nausea, vomiting > 6 hours
and vomiting. Over the last few months, he has had intermittent in duration with history of
abdominal pain after eating. These episodes last for a few biliary colic
minutes, then resolve.
Fever, tachycardia
Vitals are notable for temperature of 38.2°C (100.8°F) and
heart rate of 115/min. On abdominal exam, he has tenderness Exam and labs localize to
to palpation in the RUQ, but no rebound tenderness or biliary system
guarding. Lab studies show mild elevation in AST, ALT, and total
bilirubin. Abdominal ultrasound shows pericholecystic fluid and Ultrasound findings are
gallbladder wall thickening. concerning

What is the recommended management for this patient?

What Is the Difference between Cholelithiasis and Acute Cholecystitis?

Cholelithiasis VS. Acute cholecystitis

Acute cholecystitis presents with

Biliary colic from cholelithiasis
persistent RUQ pain, fever, and
tends to be intermittent and
elevated levels on liver
self-limited.
chemistry studies.
Acute Cholecystitis

• Symptoms: persistent RUQ pain, Inflamed gallbladder

fever, nausea, vomiting

• Physical exam:

• RUQ tenderness RUQ

LUQ
• sign (inspiration
causes gallbladder to move

causing pain)

RLQ LLQ

© by Lecturio
Acute Cholecystitis

• 90% of cases from obstruction of

cystic duct by gallstones

• Diagnosis: RUQ ultrasound (US)

Common features of cholecystitis on US:

1. Pericholecystic fluid

2. Gallbladder wall thickening

3. Gallstones

4. Sonographic sign
©2013 Mazzei et al; licensee BioMed Central Ltd., Figure 3, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711740/figure/F3/, CC BY 2.0,
edited
Acute Cholecystitis

• 90% of cases from obstruction of

cystic duct by gallstones

• Diagnosis: RUQ ultrasound (US)

Common features of cholecystitis on US:

1. Pericholecystic fluid

2. Gallbladder wall thickening

3. Gallstones

4. Sonographic sign
©2013 Mazzei et al; licensee BioMed Central Ltd., Figure 3, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711740/figure/F3/, CC BY 2.0,
edited
Acute Cholecystitis

• 90% of cases from obstruction of

cystic duct by gallstones

• Diagnosis: RUQ ultrasound (US)

Common features of cholecystitis on US:

1. Pericholecystic fluid

2. Gallbladder wall thickening

3. Gallstones

4. Sonographic sign
Quick Aside: Cholecystitis without Gallstones

Patients who are critically ill can have acalculous

cholecystitis, in which acute cholecystitis occurs in the
absence of gallstones. This usually requires percutaneous
cholecystostomy drainage.
What if Ultrasound Is Equivocal?

In cases where ultrasound is equivocal but cholecystitis is

suspected, a HIDA (hepatobiliary iminodiacetic acid) scan,
also known as cholescintigraphy, can be done.
Cholescintigraphy: HIDA Scan

1 Radiotracer (HIDA) is injected.

Radiotracer is taken up by the liver, then secreted into the biliary

2
tract.

3 Can be used to look for an obstruction anywhere along this path.

If the gallbladder is not visualized within 4 hours, suspect

4
cholecystitis or cystic duct obstruction.
Cholescintigraphy: HIDA Scan

99mTc-Mebrofenin hepatobiliary scintigraphy anterior view

© 2016 by the authors; licensee MDPI, Basel, Switzerland., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4808820/figure/diagnostics-06-
00005-f001/, CC BY 4.0, cropped
Acute Cholecystitis Management

1. Supportive care: IV fluid resuscitation

2. IV antibiotics
• Choose antibiotics that target GI flora (Gram-negatives and anaerobes)
• β-lactam/β-lactamase inhibitor

• Third-generation cephalosporin + metronidazole

3. Laparoscopic or open cholecystectomy during same hospitalization

4. If surgery is too high risk  cholecystostomy for drainage

Acute Cholecystitis Management

Percutaneous cholecystostomy
© by Lecturio
31-year-old Man with 2 Days of RUQ Pain Test case

A 31-year-old man with no past medical history presents to the RUQ pain with fever,
ED with 2 days of right upper quadrant (RUQ) pain nausea, vomiting > 6 hours
accompanied by fever, nausea, and vomiting. Over the last few in duration with history of
months, he has had intermittent abdominal pain after eating. biliary colic
These episodes last for a few minutes, then resolve.
Fever, tachycardia
Vitals are notable for temperature of 38.2°C (100.8°F) and
heart rate of 115/min. On abdominal exam, he has tenderness Exam and labs localize to
to palpation in the RUQ, but no rebound tenderness or biliary system
guarding. Lab studies show mild elevation in AST, ALT, and total
bilirubin. Abdominal ultrasound shows pericholecystic fluid and Ultrasound findings are
gallbladder wall thickening. concerning  cholecystitis

What is the recommended management for this patient?

31-year-old Man with 2 Days of RUQ Pain Answer
Test case

A 31-year-old man with no past medical history presents to the RUQ pain with fever,
ED with 2 days of right upper quadrant (RUQ) pain nausea, vomiting > 6 hours
accompanied by fever, nausea, and vomiting. Over the last few in duration with history of
months, he has had intermittent abdominal pain after eating. biliary colic
These episodes last for a few minutes, then resolve.
Fever, tachycardia
Vitals are notable for temperature of 38.2°C (100.8°F) and
heart rate of 115/min. On abdominal exam, he has tenderness Exam and labs localize to
to palpation in the RUQ, but no rebound tenderness or biliary system
guarding. Lab studies show mild elevation in AST, ALT, and total
bilirubin. Abdominal ultrasound shows pericholecystic fluid and Ultrasound findings are
gallbladder wall thickening. concerning  cholecystitis

Answer: start IV fluids (this patient meets sepsis criteria),

IV antibiotics, consult surgery for cholecystectomy
67-year-old Woman with Epigastric Pain and Jaundice Test case

A 67-year-old woman is admitted to the hospital with 2 days of triad for

epigastric abdominal pain, fever, and jaundice. Two days ago, cholangitis
she had sudden onset of abdominal pain, then noticed her
eyes and skin beginning to turn yellow. Fever, tachycardia,
leukocytosis with
Her vitals are notable for temperature 39.3°C (102.7°F), blood suspected biliary source of
pressure 105/58 mm HG, and heart rate 105/min. Abdominal infection (sepsis)
exam reveals RUQ tenderness but no guarding. Labs are
notable for WBC count 15,000/μL, ALT 550 U/L, and total Dilated bile ducts with
bilirubin 7.2 mg/dL. A RUQ ultrasound shows dilated gallstones, no signs of
intrahepatic and extrahepatic bile ducts, gallstones, a normal acute cholecystitis  stone
gallbladder wall, and no pericholecystic fluid. in common bile duct
leading to cholangitis
What is the recommended management?
Choledocholithiasis

• Gallstone impacted in the

common bile duct (CBD)

• Presents similarly to Choledocholithiasis

cholelithiasis

• Often causes transient elevation

in serum AST, ALT, and bilirubin

© by Lecturio
Choledocholithiasis

• Complications: ascending cholangitis or gallstone pancreatitis

• Diagnosis:

• MRCP (magnetic resonance cholangiopancreatography)

• RUQ ultrasound may detect ductal dilatation

• Management: ERCP (endoscopic retrograde cholangiopancreatography) for removal of

stone
Choledocholithiasis

MRCP with normal biliary ducts

© 2009 Marcouizos et al.; licensee Cases Network Ltd., Figure 2A and B, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740064/figure/fig-
002/, CC BY 3.0, cropped
Choledocholithiasis

• Complications: ascending cholangitis or gallstone pancreatitis

• Diagnosis:

• MRCP (magnetic resonance cholangiopancreatography)

• RUQ ultrasound may detect ductal dilatation

• Management: ERCP (endoscopic retrograde cholangiopancreatography) for removal of

stone
Choledocholithiasis and Gallstone Pancreatitis

Common
bile duct

Gallstones

If a gallstone blocks both the common bile duct and the pancreatic duct,
this leads to gallstone pancreatitis.
© by Lecturio
ERCP for Choledocholithiasis

Guidewire

Duodenoscope

Wire-guided
sphincterotomy
Impacted
gallstone

© by Lecturio
Ascending Cholangitis Symptoms

Fever
Fever

RUQ pain Jaundice

triad pentad

Altered
Hypotension mental
RUQ pain Jaundice status
Ascending Cholangitis Management

1. MRCP or endoscopic ultrasound to confirm diagnosis if not confirmed by abdominal

ultrasound or CT

2. Supportive care (IV fluid resuscitation)

3. Broad-spectrum IV antibiotics

• Choose antibiotics that target GI flora (Gram-negatives and anaerobes)

• β-lactam/β-lactamase inhibitor

• Third-generation cephalosporin + metronidazole

4. ERCP for sphincterotomy and stone removal

Ascending Cholangitis Management

ERCP image showing stone in

common bile duct (green arrow).

© 2012 Mehmet Bilgin et al., Figure 2, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3317552/figure/fig2/, CC BY 4.0, cropped

67-year-old Woman with Epigastric Abdominal Pain Test case

A 67-year-old woman is admitted to the hospital with 2 days of triad for

epigastric abdominal pain, fever, and jaundice. Two days ago, cholangitis
she had sudden onset of abdominal pain, then noticed her
eyes and skin beginning to turn yellow. Fever, tachycardia,
leukocytosis with
Her vitals are notable for temperature 39.3°C (102.7°F), blood suspected biliary source of
pressure 105/58 mm HG, and heart rate 105/min. Abdominal infection (sepsis)
exam reveals RUQ tenderness but no guarding. Labs are
notable for WBC count 15,000/μL, ALT 550 U/L, and total Dilated bile ducts with
bilirubin 7.2 mg/dL. A RUQ ultrasound shows dilated gallstones, no signs of
intrahepatic and extrahepatic bile ducts, gallstones, a normal acute cholecystitis  stone
gallbladder wall, and no pericholecystic fluid. in common bile duct
leading to cholangitis
What is the recommended management?
67-year-old Woman with Epigastric Abdominal Pain Answer
Test case

A 67-year-old woman is admitted to the hospital with 2 days of triad for

epigastric abdominal pain, fever, and jaundice. Two days ago, cholangitis
she had sudden onset of abdominal pain, then noticed her
eyes and skin beginning to turn yellow. Fever, tachycardia,
leukocytosis with
Her vitals are notable for temperature 39.3°C (102.7°F), blood suspected biliary source of
pressure 105/58 mm HG, and heart rate 105/min. Abdominal infection (sepsis)
exam reveals RUQ tenderness but no guarding. Labs are
notable for WBC count 15,000/μL, ALT 550 U/L, and total Dilated bile ducts with
bilirubin 7.2 mg/dL. A RUQ ultrasound shows dilated gallstones, no signs of
intrahepatic and extrahepatic bile ducts, gallstones, a normal acute cholecystitis  stone
gallbladder wall, and no pericholecystic fluid. in common bile duct
leading to cholangitis
Answer: supportive care, IV antibiotics, and ERCP
to disimpact the common bile duct
Biliary Disorders Summary
*ALP = Alkaline phosphatase
Cholelithiasis Cholecystitis Choledocholithiasis Cholangitis
Clinical Biliary colic RUQ pain Biliary colic RUQ pain
picture Self-resolves Fever Intermittent jaundice Fever
Jaundice
Lab Normal ↑ WBC ↑↑ ALP* and GGT ↑ WBC
findings May have mild ↑↑ Bilirubin ↑↑ ALP* and GGT
↑ in ALP* and ↑ AST, ALT ↑↑ Bilirubin
bilirubin ↑ AST, ALT
Diagnosis RUQ ultrasound RUQ ultrasound MRCP or MRCP or
endoscopic US Endoscopic US
Treatment Elective IV antibiotics ERCP to remove IV antibiotics
cholecystectomy Cholecystectomy stone ERCP to remove
during admission stone
Learning Outcomes

In this lecture, you have learned how to...

 distinguish between cholelithiasis and

choledocholithiasis.

 describe the basic management of acute

cholecystitis.

 identify the symptoms of ascending

cholangitis.


diagnose different gallbladder disorders.