Page 4 - 05- Cholelithiasis

Hepatitis
Pancreatitis
Cholangitis
Gallbladder cancer
Gallbladder polyps
Acalculous cholecystitis
Biliary dyskinesia
Choledocholithiasis

DIAGNOSTIC TESTS & INTERPRETATION
Ultrasound is the preferred diagnostic modality for cholelithiasis.

Initial Tests (lab, imaging)
Leukocytosis and elevated C-reactive protein level are associated with acute calculus
cholecystitis.
Ultrasound (US) is the preferred imaging modality. US detects gallstones in 97–98% of
patients.
Thickening of the gallbladder wall (≥5 mm), pericholecystic fluid, and direct tenderness when
the probe is pushed against the gallbladder (sonographic Murphy sign) are associated with
acute cholecystitis.
CT scan has no advantage over US except for detecting distal common bile duct (CBD) stones.
MR cholangiopancreatography (MRCP) is reserved for cases of suspected CBD stones.
However, MRCP has no therapeutic value, and preoperative MRCP is not more cost-effective
than initial cholecystectomy with cholangiography in the diagnosis of patients with suspected
CBD stones and patients with mild to moderate gallstone pancreatitis (GP).
Endoscopic US is as sensitive as endoscopic retrograde cholangiopancreatography (ERCP) for
detection of CBD stones in patients with GP.
Hepatobiliary iminodiacetic acid (HIDA) scan is useful in diagnosing acute cholecystitis
secondary to cystic duct obstruction. It is also useful in differentiating acalculous cholecystitis
from other causes of abdominal pain. False-positive tests can result from a fasting state,
insufficient resistance of the sphincter of Oddi, and gallbladder agenesis.
Cholecystokinin (CCK)-HIDA is specifically used to diagnose gallbladder dysmotility (biliary
dyskinesia).
10–30% of gallstones are radiopaque calcium or pigment-containing gallstones (visible on
plain x-ray). A “porcelain gallbladder” is a calcified gallbladder (also visible by x-ray) that is
associated with chronic cholecystitis and gallbladder cancer.

Test Interpretation
Pure cholesterol stones are white or slightly yellow.
Pigment stones may be black or brown. Black stones contain polymerized calcium bilirubinate,
most often secondary to cirrhosis or hemolysis; these almost always form within the
gallbladder.
Brown stones are associated with biliary tract infection, caused by bile stasis, and as such may
form either in the bile ducts or gallbladder.

TREATMENT