CLINICAL MANIFESTATIONS OF GALLSTONES
Many individuals with gallstones are asymptomatic. Duct obstruction is the underlying cause of all manifestations of gallstone disease. Obstruc-tin of the cystic duct distends the gallbladder and produces biliary pain, while superimposed infection or inflammation leads to acute cholecystitis. Obstruction of the common duct may produce pain, jaundice, infection (cholangitis), and/or pancreatitis, whereas reflux of biliary contents (and bacteria) back into the liver can produce sepsis or hepatic damage and biliary cirrhosis. The natural history of cholesterol gallstone disease is outlined in .
Asymptomatic Gallstones. Approximately 30 to 50 per cent of patients with gallstones in the United States are asymptomatic, and over a 20-year period it appears that only about 18 per cent of these individuals will develop biliary pain and only 3 per cent will require a cholecystectomy. Asymptomatic patients should be followed expectantly, with prophylactic cholecystectomy considered in three high-risk groups: (1) diabetics, who have a greater mortality (10 to 15 per cent) from acute cholecystitis; (2) persons with a calcified gallbladder, which is often associated with carcinoma of the gallbladder; and (3) persons with sickle-cell anemia in whom hepatic crises may be difficult to differentiate from acute cholecystitis. Attempts to dissolve cholesterol gallstones by orally administered chenodeoxycholic acid or ursodeoxycholic acid have been successful in some patients; however, a policy of expectant management followed by cholecystectomy is probably more cost-effective.
Chronic Cholecystitis and Biliary Colic. The term chronic cholecystitis is used to denote non-acute symptoms due to the presence of gallstones. A better term is biliary “colic,” as there is only a loose correlation between the presence of symp in the gallbladder wall. Gallbladders from symptomatic patients may be grossly normal with mild histological inflammation or may exhibit shrinking, scarring, and thickening, often as a result of previous attacks of acute cholecystitis. Symptoms arise from contraction of the gallbladder during transient obstruction of the cystic duct by gallstones. Biliary colic usually produces a steady, cramplike pain in the epigastrium or right upper quadrant which comes on quickly, reaches a plateau of intensity over a few minutes, and begins to subside gradually over 30 minutes to several hours. Referred pain may be felt at the tip of the scapula or right shoulder. Nausea and vomiting may accompany biliary colic, whereas fever, leukocytosis, and a palpable mass (signs of acute cholecystitis) do not. Attacks occur at variable intervals (days to years) and may be associated with ingestion of large or fatty meals. Other symptoms such as dyspepsia, fatty food intolerance, flatulence, heartburn, and belching may occur in patients with chronic cholecystitis; however, they are nonspecific and frequently occur in individuals with normal gallbladders. Gallstones are the sine qua non of chronic cholecystitis and can be demonstrated by either oral cholecystography (which demonstrates stones in two thirds of patients; the gallbladder is not visualized in one third of patients, a finding taken to indicate gallbladder disease) or ultrasound (which demonstrates gallstones in more than 95 per cent of patients). Cholecystectomy, which carries aof choice, and is accompanied by examination of the common duct for concomitant choledocholi-thiasis. Surgery relieves symptoms in virtually all patients and will prevent development of future complications such as acute cholecystitis, cho-ledocholithiasis and cholangitis, and gallbladder carcinoma.
Acute Cholecystitis. Acute cholecystitis refers to acute right subcostal pain and tenderness due •to obstruction of the cystic duct and subsequent distention, inflammation, and secondary infection of the gallbladder. Acalculous cholecystitis, accounting for 5 per cent of cases, is associated with prolonged fasting, e.g., trauma, surgery, or parenteral hyperalimentation, and gallbladder bile that is viscous or “sludgelike.” Acute cholecystitis usually begins with epigastric or right upper quadrant pain that gradually increases in severity and usually localizes to the area of the gallbladder. Unlike biliary colic, the pain of acute cholecystitis does not subside spontaneously. Anorexia, nausea, vomiting, fever, and right subcostal tenderness are commonly present, as is Murphy’s sign (increased subhepatic tenderness and inspiratory arrest during a deep breath). In approximately one third of patients, a tender, enlarged gallbladder may be felt. Mild jaundice occurs in about 20 per cent of patients due to concomitant common duct stones or bile duct edema. Complications of acute cholecystitis include emphysematous cholecystitis (bacterial gas present in gallbladder lumen and tissues), empyema of the gallbladder, gangrene, and perforation. Approximately 10 per cent of patients will present with or develop one of these complications and require emergency surgery. The onset of severe fever, shaking chills, increased leukocytosis, increased abdominal pain or tenderness, or persistent severe symptoms all indicate progression of disease and suggest development of one of these complications.
Radionuclide scanning following intravenous administration of 99mTc-HIDA is the most accurate test with which to confirm the clinical impression of acute cholecystitis (cystic duct obstruction). If the gallbladder opacifies, acute cholecystitis is unlikely, whereas if the bile duct opacifies but the gallbladder does not, the clinical diagnosis is strongly supported. An ultrasound examination that shows the presence of gallstones (or sludge in acalculous cholecystitis) and localized tenderness over the gallbladder also provides strong supportive evidence for acute cholecystitis. Oral cholecystograms are of no value in this clinical setting, as they are unreliable in the acutely ill patient.
Most patients with acute cholecystitis will improve over one to seven days with conventional expectant management, which includes nasogastric suction, intravenous fluids and judicious pain medication, and patients may resume oral feedings after a few days. Antibiotics are useful in conjunction with surgery to treat suppurative complications; however, their efficacy in uncomplicated acute cholecystitis is unclear. Because of the high risk of recurrent acute cholecystitis, it is recommended that most patients undergo elective cholecystectomy within four to eight weeks of an acute episode.
An alternative course of management, outlined in Figure 49-3, is to perform early (acute) cholecystectomy. This approach is becoming common practice, as it is less costly and involves no increase in morbidity or mortality. In general, emergency surgery is performed on those patients with advanced disease and complications, usually associated with infection and sepsis. Chole-cystostomy, rather than cholecystectomy, may be a useful temporizing measure in emergent circumstances in patients with a high operative risk. Patients who are good operative risks and in whom the diagnosis is certain are scheduled for prompt cholecystectomy within 24 to 48 hours. Expectant management is reserved for those with uncomplicated disease who are not good operative candidates or those in whom the diagnosis is not clear.
The mortality of acute cholecystitis of 5 to 10 per cent is almost entirely confined to patients over 60 years of age with serious associated diseases and to those with suppurative complications. Complications of acute cholecystitis include infectious complications already listed and gallstone ileus (intestinal obstruction due to a gallstone that has eroded through the gallbladder and duodenal walls into the intestinal lumen).
Choledocholithiasis and Acute Cholangitis. In the United States, most gallstones in the common duct come from the gallbladder; this occurs in up to 15 per cent of persons with cholelithiasis. Less commonly, stones may form de novo in the biliary tree, usually behind a partial obstruction. Ductal stones may be asymptomatic (30 to 40 per cent) or may produce biliary colic, jaundice, cholangitis, pancreatitis, or a combination of these. Secondary hepatic effects include biliary cirrhosis and hepatic abscesses.
Intermittent cholangitis, consisting of biliary colic, jaundice, and fever plus chills (Charcot’s triad) is the most common manifestation of choledocholithiasis, although it may also occur in patients with previous biliary surgery. Biliary infection may be mild or it may be severe, with suppurative cholangitis, sepsis, and shock. Diagnosis is based on a compatible clinical picture and radiological or endoscopic evidence of ductal stones. Treatment includes hospitalization, treatment of infection, and removal of stones. The latter may be accomplished surgically in patients with an intact gallbladder by cholecystectomy and choledochotomy. In individuals with a previous cholecystectomy or those who are poor surgical candidates, endoscopic sphincterotomy, which opens the sphincter of Oddi and allows. passage of gallstones up to 1 cm in size, is an alternative approach.
The severest form of cholangitis, suppurative cholangitis, rapidly results in life-threatening sepsis. Initially, the patients may have only mild signs of biliary obstruction, yet they require rapid evaluation and treatment, including intravenous.