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DIAGNOSIS

■ Liver function tests are normalin isolated cholelithiasis.

■ Plain X-rays are rarely diagnostic; only 10–15% of stones are radiopaque.

■ RUQ ultrasound may show gallstones (85–90% sensitive).

■ Consider upper GI series to rule out hiatal hernia or ulcer.

TREATMENT

■ Pain relief, hydration, and electrolyte replacement if severe vomiting

■ Cholecystecomy is curative and can be performed electively.

■ Patients may require preoperative ERCP for common bile duct (CBD) stones.

■ Treat nonsurgical candidates with dietary modification (avoid triggers such

as fatty foods).

COMPLICATIONS

Recurrent biliary colic, acute colecystitis, choledocholithiasis, acute cholangi-

tis, gallstone ileus, gallstone pancreatitis

Choledocholithiasis

Gallstones in the common bile duct

SYMPTOMS/EXAM

■ Symptoms vary according to degree of obstruction, duration of obstruc-

tion, and extent of bacterial infection.

■ Often presents with RUQ abdominal pain, jaundice, episodic colic, fever,

and pancreatitis

DIAGNOSIS

■ Hallmark is increased alkaline phosphatase and total bilirubin, which may

be the only abnormal lab values.

■ Ultrasound may reveal a dilated common bile duct or intrahepatic ducts.

■ Magnetic resonance cholangiopancreatography (MRCP) also very helpful

for visualizing extra hepatic, intrahepatic, and pancreatic ducts

TREATMENT

■ ERCP with sphincterotomy followed by semielective cholecystectomy

Cholecystitis

Prolonged blockage of the cystic duct, usually by an impacted stone →

obstructive distention, inflammation, superinfections, and possible gangrene

of the gallbladder (acute gangrenous cholecystitis). Acalculous cholecystitis

occurs in the absence of cholelithiasis in chronically debilitated patients, clas-

sically those on TPN and trauma or burn victims.

SYMPTOMS

■ Patients present with RUQ abdominal pain, nausea, fever, and vomiting.

Symptoms are typically more severe and of longer duration than those of

biliary colic.

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES