Clinical presentation of stones in the gallbladder

Since the sixteenth century it has been realized that most people who have gallstones remain asymptomatic throughout their lives. In a few patients stones are discovered by accident during the investigation of some other problem. In general these stones should be left alone. In a study of patients in whom gallbladder stones were discovered on screening, only 15 per cent developed biliary pain in the subsequent 15 years.

 

There may be a case for removing asymptomatic stones in diabetics because of their greater susceptibility to infection, and an incidental cholecystectomy for gallstones during a laparotomy for an unrelated condition may sometimes be appropriate because such patients are at greater risk of developing subsequent symptoms. There is no justification for removing the gallbladder with stones to prevent the later development of cancer.

 

Disease in the gallbladder affects only a small minority of people with gallstones. It presents with a variety of clinical syndromes, of which the most common are chronic cholecystitis, which appears slowly over time, biliary colic, and acute cholecystitis, both of which develop rapidly. Patients occasionally present with the complications of one of these three, either locally in the gallbladder or from stones in the bile duct, and very occasionally from a stone that has ulcerated through into the bowel.

 

Chronic cholecystitis

Pathology

About two-thirds of patients present with chronic cholecystitis. The pathological changes, which often do not correlate well with symptoms, vary from those of an apparently normal gallbladder with minor chronic inflammation in the mucosa to a shrunken organ with gross transmural fibrosis and organized adhesions (Fig. 25) 1248. The mucosa is initially hypertrophied but later becomes atrophied; the epithelium protrudes into the muscle coat, leading to the formation of Rokitansky-Aschoff sinuses. The most severe form is represented by cholecystitis glandularis proliferans in which there are buried areas of hyperproliferative epithelium within the wall of the gallbladder (see Fig. 28 1251 below). Rarely, dystrophic calcification may occur, resulting in the formation of a porcelain gallbladder (Fig. 26) 1249.

 

Diagnosis

The typical patient complains of recurrent attacks of right hypochondrial or epigastric pain, usually after meals, and particularly after consumption of fatty foods. The pain, which often occurs at night, varies from mild indigestion after eating to persistent, moderately severe, right upper quadrant pain which may radiate round to the back and sometimes to the right shoulder or between the shoulder blades. The pain is often described as a tight band all the way round the upper abdomen; very occasionally the pain on the right hand side of the abdomen is suppressed and the patient presents only with left-sided pain.

 

Nausea usually accompanies the pain, sometimes associated with vomiting. There may be additional minor symptoms such as flatulence and abdominal distension, but these are equally common in patients who do not have gallstones. There may be mild right upper quadrant abdominal tenderness, but examination is usually unremarkable.

 

It is often possible to make a confident clinical diagnosis of chronic cholecystitis in a patient with classical symptoms, but the presence of gallstones should be confirmed by ultrasonography (Fig. 9) 1232. Occasionally an oral cholecystogram is also needed. When it is difficult to distinguish chronic cholecystitis from peptic ulceration, a hiatus hernia, or diverticular disease, further radiology and endoscopy may be required. The last two conditions often occur together with gallstones, a condition known as Saint's triad.

 

It is easy to ascribe the patient's symptoms to stones which are found on investigation when this is not the case: many patients with other conditions have gallstones. On the other hand patients with symptoms that show enough features related to proven gallstones are likely to improve on treatment.

 

Treatment

Once the diagnosis is established some form of active treatment is indicated since the symptoms will almost always continue. Some patients can control their symptoms by taking care over their diet. Others are only occasionally troubled and simply require mild analgesia. More commonly, some form of surgical treatment is needed to remove the stones, with or without the gallbladder. The risks of surgery must be balanced against the potential benefits, and the views of the informed patient are just as important as the opinion of the doctor. Most surgeons prefer the patient to request the operation.

 

Biliary colic

Biliary colic is due to impaction of a stone in the neck of the gallbladder. The severe pain starts abruptly in the epigastrium, often at night after a heavy meal, and lasts for several hours. It is usually continuous and is associated with restlessness, vomiting, and sweating. The pain may radiate through to the back but does not radiate to the shoulder, as in acute cholecystitis. General examination may disclose a patient in obvious severe pain with a mild tachycardia and normal temperature. Abdominal examination shows only mild tenderness in the epigastrium. In contrast to acute cholecystitis, tenderness over the gallbladder is absent. The gallbladder in patients with biliary colic is often normal in external appearance and shows only mild inflammatory changes on histological examination. Most patients need a strong analgesic given by injection, and after two attacks of severe biliary colic will want some form of definitive treatment.

 

Acute cholecystitis

Pathology

About one-fifth of patients first present with acute cholecystitis; in about one-third there is clinical or pathological evidence of previous chronic cholecystitis. It is usually due to persistent impaction of a stone in the neck of the gallbladder. The result is initially a chemical inflammation of the gallbladder wall perhaps due to the mucosal toxin lysolecithin, produced by the action of phospholipase on biliary lecithin. This is soon followed by bacterial infection. Because the cystic duct is occluded the inflammatory process is particularly aggressive and the gallbladder becomes acutely distended, with accompanying lymphatic and venous obstruction. The serosa may be covered by a fibrinous exudate and subserosal haemorrhage gives the appearance of patchy gangrene. The gallbladder wall itself is grossly thickened and oedematous and the underlying mucosa may show hyperaemia or patchy necrosis (Fig. 27) 1250. Histologically, three grades of inflammation are recognized: acute cholecystitis, acute suppurative cholecystitis, and acute gangrenous cholecystitis. Rarely an abscess or empyema develops within the gallbladder, while perforation of an ischaemic area leads to a pericholecystic abscess, bile peritonitis, or a cholecystoenteric fistula.

 

Diagnosis

Patients present with acute upper abdominal pain that has often been present for 2 or 3 days. Because the inflammation extends to the parietal peritoneum the pain is well localized and it hurts the patient to move or to breathe. Patients feel generally unwell, may have been febrile, and are anorexic. Physical signs vary with the severity of the inflammation but there is usually some degree of fever and tachycardia. Mild jaundice is present in 10 to 15 per cent of patients. Right hypochondrial tenderness is invariable and there may also be guarding, rigidity, and rebound tenderness. If the latter physical signs are subdued it may be possible to feel the gallbladder itself. Murphy's sign (inspiratory arrest during subcostal palpation) is widely regarded as pathognomonic of cholecystitis. It is certainly present in patients with established acute cholecystitis, but it only reflects peritoneal inflammation in the right upper quadrant, other causes of which include chronic cholecystitis, acute hepatitis, and a localized abscess around a perforated duodenal ulcer. There is usually a clear distinction between acute cholecystitis and biliary colic: this is important since the management is different.

 

In elderly patients acute cholecystitis may present more insidiously and the frequent absence of typical physical signs results in a delay in diagnosis. In addition, the incidence of complications is higher and the prevalence of intercurrent illness combine to increase the mortality rate 10-fold. Acute cholecystitis is uncommon in children, most of whom have gallstones, sometimes as a complication of haemolytic disease. Acalculous cholecystitis occurs in children with severe sepsis.

 

Differential diagnosis

Clinically it can be difficult to distinguish acute cholecystitis from acute pancreatitis, acute appendicitis, acute pyelonephritis, perforation of a peptic ulcer, and, occasionally, biliary colic. A raised white cell count and serum amylase level may occur in several of these conditions, although patients with biliary colic rarely have a leucocytosis. Urine should always be examined under the microscope for pus cells and sent for culture if appropriate. One-quarter of patients have disturbed liver function tests, but not all will have stones in the bile duct. There are rarely any specific features of acute cholecystitis on plain radiology, but ultrasound may localize the tenderness to the gallbladder and may demonstrate stones. Free air under the diaphragm on a chest radiograph implies perforation of a viscus, usually a peptic ulcer. A normal HIDA scan excludes acute cholecystitis (Fig. 15) 1238.

 

Young women who present acutely with severe right upper quadrant pain and signs of peritonitis may have the Curtis& ndash; Fitz& ndash; Hugh syndrome. Clinically these patients appear to have acute cholecystitis but ultrasound examination fails to show gallstones or any signs of acute cholecystitis. At laparoscopy or laparotomy the gallbladder is normal but there are string-like adhesions between the liver and the peritoneum. This perihepatitis is caused by infection with Chlamydia trachomatis. There may also be evidence of genital tract infection with the same organism. The diagnosis can be confirmed by isolation of the organism from peritoneal fluid or by rising titres of chlamydial antibodies in serum. Treatment is with oxytetracycline 2 g daily for 10 days.

 

Acute viral hepatitis can sometimes present as acute cholecystitis. The acutely swollen liver is painful and tender but the systemic symptoms and the onset of jaundice soon make the true diagnosis clear.

 

Treatment

Acute cholecystitis resolves with conservative treatment in the majority of cases. If admission to hospital is necessary patients require intravenous fluids, analgesia, and suspension of oral intake. Vomiting is unusual, but if present nasogastric aspiration is helpful. If the patient fails to respond intravenous antibiotics are prescribed. Our present choice is cefuroxime 1.5 g three times a day.

 

Most patients should be offered cholecystectomy, which should normally be undertaken on the next convenient operating list. There is no advantage in letting the acute illness subside and removing the gallbladder 6 weeks later except in a patient who is unfit for surgery and whose condition could be improved by waiting.

 

Complications

An empyema of the gallbladder may be suspected clinically if the physical signs and symptoms fail to improve on conservative management. In particular, fever and right upper quadrant tenderness fail to abate, and there is a persistent or increasing leucocytosis. With time the gallbladder becomes necrotic and ruptures, resulting either in a localized abscess or in generalized peritonitis. An empyema is really an abscess within the gallbladder and it must therefore be drained. The best method is to insert a pigtail catheter into the gallbladder under ultrasound control, as the gallbladder is usually adherent to the peritoneum of the abdominal wall. If there is any doubt a transhepatic route for the catheter should be chosen. Percutaneous drainage is clearly less disturbing for the patient, who is usually quite ill and toxic. If it fails for any reason a conventional surgical approach must be adopted. Occasionally a safe cholecystectomy can be performed by an experienced surgeon. For everyone else a cholecystostomy is better.

 

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