Cholelithiasis

Key Features

Essentials of Diagnosis

• Episodic right upper quadrant abdominal pain

• Elevated bilirubin, alkaline phosphatase, and γ-glutamyl transpeptidase (GGT)

• Stones or sludge seen on abdominal ultrasound

General Considerations

• Gallstones may develop at all ages in the pediatric population and in utero

• May be divided into cholesterol stones (> 50% cholesterol) and pigment (black [sterile bile] and brown [infected bile]) stones

• Groups at risk for gallstones

  • Patients with known or suspected hemolytic disease

  • Females

  • Teenagers with prior pregnancy

  • Obese persons or individuals with rapid weight loss

  • Children with portal vein thrombosis

  • Certain ethnic groups, particularly Native Americans (Pima Indians) and Hispanics

  • Infants and children with ileal disease (Crohn disease) or prior ileal resection

  • Patients with cystic fibrosis or Wilson disease

  • Infants receiving prolonged parenteral hyperalimentation

  • Infants with bile acid transporter defects

• Other, less certain risk factors

  • Positive family history

  • Use of birth control pills

  • Diabetes mellitus

Clinical Findings

Symptoms and Signs

• Acute or recurrent episodes of moderate to severe, sharp right upper quadrant, or epigastric pain

  • May radiate substernally or to the right shoulder

  • Episodes often occur postprandially, especially after ingestion of fatty foods

  • Tenderness is present, with a positive inspiratory arrest (Murphy sign), usually without peritoneal signs

• Nausea and vomiting may occur during attacks

• On rare occasions, presentation may include a history of jaundice, back pain, or generalized abdominal discomfort, when it is associated with pancreatitis

• While rarely present, scleral icterus is helpful

• Evidence of underlying hemolytic disease in addition to icterus may include pallor (anemia), splenomegaly, tachycardia, and high-output cardiac murmur

• Fever is unusual in uncomplicated cases

Differential Diagnosis

• Liver disease (hepatitis, abscess, or tumor) can cause similar symptoms or signs

• Peptic disease, reflux esophagitis, paraesophageal hiatal hernia, cardiac disease, and pneumomediastinum must be considered when the pain is epigastric or substernal in location

• Renal or pancreatic disease is a possible explanation if the pain is localized to the right flank or mid back

• Subcapsular or supracapsular lesions of the liver (abscess, tumor, or hematoma) or right lower lobe infiltrate may also be a cause of nontraumatic right shoulder pain

Diagnosis

Laboratory Findings

• Usually normal

• However, serum bilirubin and GGT (or alkaline phosphatase) may be elevated if calculi have lodged in the extrahepatic biliary system

• Amylase and lipase levels may be increased if stone obstruction occurs at the ampulla hepatopancreatica

Imaging

• Ultrasonography

  • Best imaging technique

  • Shows abnormal intraluminal contents (stones, sludge) as well as anatomic alterations of the gallbladder or dilation of the biliary ductal system

• In selected cases, endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP), or endoscopic ultrasound may be helpful in defining subtle abnormalities of the bile ducts and locating intraductal stones