Internal Medicine

0521779407-08 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:47

602 Gallstone Disease

tests

Laboratory

■uncomplicated biliary colic: no changes in hematological/bio-

chemical tests

■acute cholecystitis: leukocytosis with a “left shift”

■liver enzymes, bilirubin and amylase

Imaging

■ultrasound: high sensitivity (>95%) and specificity (>95%) for the

diagnosis of gallstones greater than 2 mm in diameter; ultrasound

less sensitive for the diagnosis of choledocholithiasis and may only

document half of CBD stones

■ERCP is the gold standard for the diagnosis of choledocholithiasis;

additional benefit of providing therapeutic options

■CT and MRI now approach the diagnostic accuracy of ERCP

■hepatobiliary scintigraphy can confirm or exclude acute cholecysti-

tis

■bile microscopy (idiopathic pancreatitis)

differential diagnosis

What to Do First

■management varies with the extent, severity and type of gallstone-

induced complications

General Measures

■blood cultures, intravenous broad-spectrum antibiotics and transfer

to intensive care unit in patients with cholangitis

management

Asymptomatic Gallstones

■adult patients with silent or incidental gallstones can be managed

expectantly;

■exceptions include asymptomatic individuals with a calcified gall-

bladder (porcelain gallbladder), large gallstones (>2.5 cm), gall-

bladder polyp greater than 10 mm in diameter, and certain Native

Americans (Pima Indians) at higher risk for developing gallbladder

cancer

Symptomatic Gallstones

■after an episode of biliary colic, up to 70% of patients will have

recurrence of biliary colic (risk of developing gallstone-induced