Presentation
Majority of patients do not show any symptoms but when symptoms are available the first complaint is pain [7]. The pain begins abruptly and occurs immediately after the consumption of a large fatty meal. The pain is generally located in the right upper and upper central epigastrium or middle abdomen. This pain can be intense and may spread into the back, scapula or shoulder and can last minutes to hours. In some cases the pain may be accompanied by nausea and vomiting as well as belching and bloating. The last two are not specific to cholelithiasis.
Entire Body System
- Pain
Absence of abdominal pain was reported by 60.3% of the patients. Patients classified as ASA II as opposed to ASA I were less likely to report absence of pain (OR 0.41, 95% CI 0.17-0.99). [ncbi.nlm.nih.gov]
Calcareous stones may form in the bile ducts of cattle with distomiasis. obstructive cholelithiasis blockage of the common bile duct by a gallstone; characterized clinically by severe jaundice, abdominal pain. [medical-dictionary.thefreedictionary.com]
pain with distention of the gallbladder as compared to the common duct. [jamanetwork.com]
The obstruction or irritation by the stone causes inflammation and pain. The pain can be of two types. [youtube.com]
- Fever
Usually have abnormalities in liver enzymes and pain but no fever. The 2 major complications are 1) Cholangitis and 2) Acute pancreatitis. [sketchymedicine.com]
Dry and yellow (more Heat) P: Wiry, slippery and rapid or Rolling and rapid or Slippery and rapid Heat greater than Dampness : Maybe Yang jaundice (sclera, mucosal membranes and skin bright orange-yellow) Fever or Alternating fever and chills Thirst [americandragon.com]
malaise, anorexia Nausea and vomiting Acute cholecystitis should always be suspected in a patient with a history of gallstones who presents with RUQ pain, fever, and leukocytosis. [amboss.com]
A 10-year-old girl visited our hospital because of right epigastric pain and fever. Cholelithiasis and choledocholithiasis were diagnosed by ultrasound examination. [ncbi.nlm.nih.gov]
- Anorexia
[…] chills and fever Fullness and focal distention in the chest and diaphragm Pain in the chest and diaphragm with pressure Thick, sticky, difficult-to-expectorate Phlegm Panting A bitter taste in the mouth Chest pain with coughing or on deep inhalation Anorexia [americandragon.com]
The statistical results of symptoms and signs in two trials (Chi2 test or Fischer's exact test) The statistical results of trials (Chi 2 (P)) Upper abdominal pain Nausea and vomiting Abdominal distension Anorexia Belching Icterus Murphy's sign Tenderness [cochranelibrary.com]
[…] pain More severe and prolonged (> 6 hours) than in cholelithiasis Postprandial Radiation to the right scapula Positive Murphy sign: sudden pausing during inspiration upon deep palpation of the right upper quadrant due to pain Guarding Fever, malaise, anorexia [amboss.com]
Gastrointestinal
- Vomiting
Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride. Eliminate noxious sights or smells from environment. Reduces stimulation of vomiting center. [nurseslabs.com]
+ PC-6 For vomiting : + PC-6 For jaundice : SJ-9 For back pain : + UB-18 For rib pain : GB-40, SJ-3 For biliary colic : 1. [americandragon.com]
Occasional nausea and vomiting may occur in milder cases. More extreme cases are characterized by intractable vomiting, dehydration, severe right upper quadrant or epigastric pain, and pain that radiates to the tip of the right scapula. [cancertherapyadvisor.com]
B.Chief complain Fever, vomiting, indigestion, diarrhea. Pain on the right side 8. C. Present Illness/ Health Status Ms. [slideshare.net]
When this happens, a child may have abdominal pain and nausea, vomiting or fever. How do gallstones form? Normally, bile drains from the liver into the small intestine where it helps digest food. Between meals, bile is stored in the gallbladder. [childrenshospital.org]
- Nausea
Clinical Manifestations Steady, severe pain in the right upper quadrant or Epigastric pain Nausea Vomiting Jaundice Fever Treatment Principle Herb Formulas Points GB-34, LI-11, LIV-4 (right side), PC-4, ST-36, UB-18, UB-19, UB-22 Sedate GB-33, GB-38, [americandragon.com]
When this happens, a child may have abdominal pain and nausea, vomiting or fever. How do gallstones form? Normally, bile drains from the liver into the small intestine where it helps digest food. Between meals, bile is stored in the gallbladder. [childrenshospital.org]
When such an obstruction occurs, you might experience the following: Severe and sudden pain in the upper right abdomen and possibly extending to the upper back Fever and shivering Severe nausea and vomiting Jaundice (yellowing of the skin or eyes) Clay [webmd.com]
Occasional nausea and vomiting may occur in milder cases. More extreme cases are characterized by intractable vomiting, dehydration, severe right upper quadrant or epigastric pain, and pain that radiates to the tip of the right scapula. [cancertherapyadvisor.com]
- Abdominal Pain
The episodic nature of abdominal pain associated with symptomatic cholelithiasis warrants long-term follow-up studies. [ncbi.nlm.nih.gov]
Calcareous stones may form in the bile ducts of cattle with distomiasis. obstructive cholelithiasis blockage of the common bile duct by a gallstone; characterized clinically by severe jaundice, abdominal pain. [medical-dictionary.thefreedictionary.com]
Go to a hospital emergency department if the person has this abdominal pain with any of the following conditions: the abdominal pain cannot be controlled with over-the-counter pain medication; the person begins vomiting or develops a fever, chills, or [emedicinehealth.com]
Abdominal pain is often referred to the right shoulder. Patients may demonstrate this radiation to the tip of the scapula by placing their hand behind the back and thumb pointing upwards: "Collins sign". [radiopaedia.org]
- Right Upper Quadrant Pain
Two months later, she presented with right upper quadrant pain. Diagnostic studies including ultrasonography (US), computed tomography (CT) and endoscopic retrograde cholangiography (ERC), led to the diagnosis of cholecystohepatolithiasis. [ncbi.nlm.nih.gov]
Right upper quadrant pain. Investigations ERCP investigation can detect and remove the stone. [youtube.com]
First published on SonoWorld Case Presentation 35 year old female presents with right upper quadrant pain. Caption: Transverse Image of Right Upper Quadrant. | Description: The gallbladder demonstrates tiny gallstones. [123sonography.com]
The classic presentation of persons experiencing cholelithiasis, specifically when gallstones obstruct the common bile duct, is right upper quadrant pain of the abdomen that is often elicited upon palpation during physical examination and documented as [onlinelibrary.wiley.com]
- Dyspepsia
Flatulent dyspepsia. Gallstone colic. Acute Obstructive cholecystitis which may lead to: Mucocele. Empyema. Gangrene. Perforation. Fistula. Chronic Cholecystitis. Carcinoma. In the CBD: Obstructive jaundice.. Liver failure. Cholangitis. [en.wikibooks.org]
Artichoke leaf extract reduces mild dyspepsia in an open study.Phytomedicine. 2002 Dec;9(8):694-9. 15. Holtmann, et al. [passeportsante.net]
Patients with cholelithiasis often have other illnesses (e.g. peptic ulcer, gastro-oesophageal reflux disease, lactose intolerance, coeliac disease, functional dyspepsia, irritable bowel syndrome, pancreatitis or even cancer). [books.google.de]
The most common symptom is biliary colic; gallstones do not cause dyspepsia or fatty food intolerance. [merckmanuals.com]
Liver, Gall & Pancreas
- Jaundice
After "simple" cholecystectomy for lithiasis, biliary disorders can appear, with the onset more than 3 years postoperative, like cholangitis or transitory jaundice. [ncbi.nlm.nih.gov]
You notice jaundice; gallstones may be obstructing the bile duct, causing bile to back up into the liver and seep into your bloodstream. [webmd.com]
Gallbladder mass which is generally a late finding and it is associated with jaundice found in less than 10 percent of cases. [youtube.com]
When stones develop within this organ, it may give rise to excruciating pain along with jaundice. Treatment is essential immediately after detection as gallstones may lead to severe complications. [practo.com]
- Biliary Colic
The symptom that develops most commonly is biliary colic rather than a major biliary complication. [merckmanuals.com]
Cardiovascular
- Retrosternal Chest Pain
CASE PRESENTATION: We present here two females of Aryan ethnicity, one 55 and another 45 years old, who presented with pain at upper abdomen and retrosternal chest pain; on investigations were found to have cholelithiasis along with Morgagni hernia which [ncbi.nlm.nih.gov]
Musculoskeletal
- Back Pain
[…] below your breastbone Back pain between your shoulder blades Pain in your right shoulder Nausea or vomiting Gallstone pain may last several minutes to a few hours. [mayoclinic.org]
[…] in the right side of the body, below the ribs Gallstones cause back pain Nausea Vomiting Sweating Restlessness Other symptoms of gallstones may include jaundice, infections, pancreatitis, and biliary colic — a painful condition where a gallstone passes [belmarrahealth.com]
Case 10: Back pain Case 11: Dark stools Case 12: Chest pain Case 13: Chest pain Case 14: Chest pain Case 15: Chronic abdominal pain Case 16: Trouble sleeping Case 17: Forgetfulness Case 18: Cough Case 19: Cough Case 2: Abdominal pain Case 20: Decreased [amboss.com]
+ PC-6 For vomiting : + PC-6 For jaundice : SJ-9 For back pain : + UB-18 For rib pain : GB-40, SJ-3 For biliary colic : 1. [americandragon.com]
Skin
- Pruritus
Angioedema, dry skin, hair texture abnormal, nail disorder, onychoclasis, photosensitivity reaction, pruritus generalized, rash maculo-papular, rash pruritic, Last Update: 2012-04-11 Usage Frequency: 2 Quality: Reference: Wikipedia Estonian kui teil [mymemory.translated.net]
Steatorrhea, dark amber urine, constipation, jaundice, clay colored stools, pruritus (itchy) Lab values WBC count elevated (leukocytosis) normal is 5-10K, liver function studies (enzymes could be high), serum bilirubin (enzymes could be high) Ultrasound [quizlet.com]
• If obstruction is present, the patient may complain of fever, clay-colored stool, tea-colored urine, jaundice, nausea and vomiting, pruritus, and symptoms specific to pancreatitis.• On examination, the patient may appear jaundiced and RUQ tenderness [scribd.com]
Inform the patient and family about symptoms that should be reported to the physician, including jaundice, dark urine, pale-colored stools, pruritus, or signs of inflammation and infection, such as pain or fever. Emphasize importance of keeping [slideshare.net]
[…] common): history of cholelithiasis Clinical features [18][7] Colicky RUQ/epigastric pain More severe and prolonged (> 6 hours) than in cholelithiasis Postprandial Nausea, vomiting Signs of extrahepatic cholestasis: jaundice, pale stool, dark urine, pruritus [amboss.com]
- Yellow Discoloration of the Skin
Jaundice, a yellow discoloration of the skin and the sclera of the eyes, occurs when the common bile duct is obstructed because of an impacted stone in Hartmann’s pouch (Mirizzi’s syndrome). [uspharmacist.com]
Urogenital
- Dark Urine
urine Biliary colic is a separate condition caused when a gallstone is temporarily blocking the bile duct. [webmd.com]
The presence of associated bile duct stones (choledocholithiasis) should be suspected through clinical signs such as jaundice and dark urine (bilirubinuria), together with radiologic and laboratory findings, such as bile duct dilation or increases in [link.springer.com]
The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, and usually described as clay-colored Obstruction of bile flow also interferes with [slideshare.net]
Workup
On physical examination, everything appears normal apart from the possible tenderness in the right abdomen [8]. On rare occasions, an enlarged gallbladder may be felt when pressing the abdomen. Fever, tachycardia and hypotension may lead to complications such as the infection of biliary tree (cholangitis) or the inflammation of the gallbladder. Jaundice may be seen if the gallstones lead to obstruction of the common bile duct.
Plain radiographs, CT scans and abdominal sonograms are some of the diagnostic procedures often used as they have been able to pick up asymptomatic gallstone cases when focus was on diagnosis of other conditions.
Biopsy
- Hepatocellular Carcinoma
Heatstroke Helminth infections Hemochromatosis Hemolytic anemia Hemolytic disease of the fetus and newborn Hemolytic uremic syndrome Hemophilia Hemorrhoids Hemostasis and bleeding disorders Henoch-Schonlein purpura Hepatitis A Hepatitis B Hepatitis C Hepatocellular [amboss.com]
ICC, the second most frequent liver neoplasm following hepatocellular carcinoma, is highly malignant and shows extremely poor prognosis [ 3 ]. The incidence of ICC is relatively low but increasing worldwide [ 4, 5 ]. [bmccancer.biomedcentral.com]
Laboratory
- Leukocytosis
There will also be a fever (no rigors) leukocytosis. Gallbladder mass which is generally a late finding and it is associated with jaundice found in less than 10 percent of cases. [youtube.com]
Steatorrhea, dark amber urine, constipation, jaundice, clay colored stools, pruritus (itchy) Lab values WBC count elevated (leukocytosis) normal is 5-10K, liver function studies (enzymes could be high), serum bilirubin (enzymes could be high) Ultrasound [quizlet.com]
Laboratory values include a mild leukocytosis (typically less than 15,000), and mildly abnormal transaminases. An elevated amylase suggests gallstone pancreatitis. Jaundice or elevated total bilirubin suggests obstruction of the common bile duct. [cancertherapyadvisor.com]
Treatment
Unless the gallstones are very large or there is a significant risk of complications, cholelithiasis doesn’t require any treatment. Some common medical treatments for gallstones that may be used alone or in combination include contact dissolution, extracorporeal shockwave lithotripsy and oral bile salt therapy (ursodeoxycholic acid) [9].
Prognosis
In most cases, the prognosis for cholelithiasis is very positive as 80% of patients do not develop any symptoms [6]. Small stones generally find a way into the intestine and leave the body with stool.
Recurrence is often prevented with the aid of elective cholecystectomy, however chronic diarrhea may arise as a result of bile salts. Missed diagnosis or motility disorder may also lead to recurrent pain.
Etiology
In many cases, cholelithiasis arises as a result of excess amounts of cholesterol in the bile which is stored in the gallbladder [3]. The excess cholesterol hardens, forming stone-like substances. The rising levels of cholesterol in the bile can be attributed to increased body weight and older age. This is why this condition is seen mostly in older individuals, overweight people and women. Cholelithiasis may also develop as a result of the bile containing excess bilirubin.
Epidemiology
Cholelithiasis is a common problem in most western cultures [4]. As much as 3% of the population show symptoms of having this condition. In the United States for example, around 500,000 people show symptoms of gallstones that may lead to them needing a cholecystectomy. It is also responsible for the death of at least 10,000 people each year.
The incidence of cholelithiasis is far lower in other regions such as Asia and the African continent.
Pathophysiology
The first step to the development of gallstones is the formation of biliary sludge [5]. The sludge is made up of Ca bilirubinate, mucin and cholesterol microcrystals. Sludge develops during gallbladder stasis as is seen in pregnant women. The gallstones leading to cholelithiasis are divided into three types.
The first is cholesterol stones which make up more than 85% of gallstone cases in the Western World.
The second is black pigment stones which are hard gallstones that are made up of Ca bilirubinate and inorganic Ca salts. The development of these stones is accelerated by alcoholic liver disease, chronic hemolysis and old age.
The third type of gallstones is brown pigment stones. These are soft and greasy and made of bilirubinate and fatty acids. They often form during infection, inflammation as well as parasitic infestation.
Gallstones generally grow at a pace of 1 to 2 mm/yr. Therefore is will take between 5 and 20 years for them to become large enough to become a medical concern. The first two forms of gallstones form within the gallbladder but brown pigment stones generally form in the ducts. Gallstones may end up migrating to the bile duct following a cholecystectomy and in the case of brown pigment stones they can develop behind strictures as a result of stasis and infection.
Prevention
Common tips in the prevention of gallstones include [10]:
- Avoiding fasts or skipping meals
- Losing weight slowly
- Maintaining a healthy weight
- Getting an ursodeoxycholic acid treatment
Summary
Cholelithiasis is a medical disorder that signifies the presence of gallstones in the gallbladder [1]. It is relatively common as around 10 to 20% of adults develop the condition in their life time.
The course cholelithiasis takes varies from one individual to the other but majority of those that develop it do not show any symptoms at all.
It is important for the condition to be treated as it can lead to serious problems such as tissue damage, tears in the gallbladder and infections that may spread to other parts of the body [2].
Patient Information
Gallstones or cholelithiasis refer to hardened deposits of digestive fluid which may form in the gallbladder. The gallbladder is a small organ on the right side of the abdomen and is located just below the liver. The gallbladder has a digestive fluid that that is known as bile which gets released into the small intestine of every human.
Gallstones often vary in size. They can be as a small as a grain of sand and in extreme cases , they may be as large as a golf ball. In some patients, only one gallstone is seen. In others, several gallstones may form.
The condition is relatively common in the western world. People who have gallstones often need a gallbladder surgery. Gallstones that don’t have any signs or symptoms generally do not need any treatment.
References
- Wang DQH, Afdhal NH (2010). Gallstone disease. In M Feldman et al., eds., Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 9th ed., vol. 1 , pp. 1089–1120. Philadelphia: Saunders.
- Huang CS, Lichtenstein DR (2006). Biliary tract stones. In MM Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 395–408. Philadelphia: Saunders Elsevier.
- Sanders G, Kingsnorth AN (2007). Gallstones. BMJ, 335(7614): 295–299.
- Heuman DM, Moore EL, Vlahcevic ZR. Pathogenesis and dissolution of gallstones. In: Zakim D, Boyer TD, eds. Hepatology: A Textbook of Liver Disease. 1996. 3rd ed. Philadelphia, Pa: WB Saunders; 1996:376-417.
- Acalovschi M, Blendea D, Feier C, Letia AI, Raitu N, Dumitrascu DL, Veres A. Risk factors for symptomatic gallstones in patients with liver cirrhosis: a case-control study. The American Journal of Gastroenterology 2003 98 (8): 1856–1860
- Center SA. Diseases of the gallbladder and biliary tree. Vet Clin North Am Small Anim Pract. May 2009;39(3):543-98.
- Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet. Jul 15 2006;368(9531):230-9.
- Poupon R, Rosmorduc O, Boëlle PY, Chrétien Y, Corpechot C, Chazouillères O, et al. Genotype-phenotype relationships in the low-phospholipid associated cholelithiasis syndrome. A study of 156 consecutive patients. Hepatology. Mar 26 2013.
- Halldestam I, Kullman E, Borch K. Incidence of and potential risk factors for gallstone disease in a general population sample. Br J Surg. Nov 2009;96(11):1315-22.
- Shaffer EA. Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century?. Curr Gastroenterol Rep. May 2005;7(2):132-40.