White blood cell counts and serum levels of C-reactive protein, bilirubin, aminotransferases, and alkaline phosphatase are usually elevated. Acute cholecystitis is primarily a clinical diagnosis and typically does not require additional imaging beyond ultrasonography. When there is discordance between clinical and ultrasonographic findings, the most accurate second imaging test is scintigraphy of the biliary tract, usually performed with technetium-labeled hydroxy iminodiacetic acid.
Given intravenously, the radionuclide is rapidly taken up by the liver and then secreted into the bile. In acute cholecystitis, the cystic duct is functionally occluded and the isotope does not enter the gallbladder, creating an imaging void compared with a normal appearance.
Even though scintigraphy is more sensitive, abdominal ultrasonography is often the initial test for patients with suspected acute cholecystitis because it is more widely available, takes less time, does not involve radiation exposure, and can assess for the presence or absence of gallstones and dilation of the intra- and extrahepatic bile ducts. When acute cholangitis due to choledocholithiasis is suspected, abdominal ultrasonography is a prudent initial test to look for gallstones or biliary dilation suggesting obstruction by stones in the common bile duct.
The normal bile duct diameter ranges from 3 to 6 mm, although mild dilation is often seen in older patients or after cholecystectomy or Roux-en-Y gastric bypass surgery. ERCP should be reserved for managing rather than diagnosing common bile duct stones because of the risk of pancreatitis and perforation. Patients undergoing cholecystectomy who are suspected of having choledocholithiasis may undergo intraoperative cholangiography or laparoscopic common bile duct ultrasonography.
The management of patients with asymptomatic gallstones typically is based on the risk of developing symptoms or complications. Standard treatment for these patients is expectant management. Cholecystectomy is not recommended for patients with asymptomatic gallstones. We and others 48 suggest considering cholecystectomy in the following patients. Patients with chronic hemolytic anemia including children with sickle cell anemia and spherocytosis.
These patients have a higher risk of developing calcium bilirubinate stones, and cholecystectomy has improved outcomes. Native Americans, who have a higher risk of gallbladder cancer if they have gallstones. This condition was thought to be associated with a high rate of gallbladder carcinoma, but analyses of larger, more recent data sets found much smaller risks.
Thus, prophylactic cholecystectomy is no longer recommended in asymptomatic cases of porcelain gallbladder. In addition, concomitant cholecystectomy in patients undergoing bariatric surgery is no longer considered the therapeutic standard. Historically, cholecystectomy was performed in these patients because of the increased risk of gallstones associated with rapid weight loss after surgery. However, research now weighs against concomitant cholecystectomy with bariatric surgery and most other abdominal surgeries for asymptomatic gallstones.
Patients with symptomatic gallstones are at high risk of biliary complications. Laparoscopic cholecystectomy is recommended for patients who can undergo surgery Figure 1. Clinical management and emergency laparoscopic cholecystectomy are recommended for large pigmented or radiopaque stones. Otherwise, clinical follow-up is recommended.
Figure 1. Management of patients with gallstones. For patients experiencing acute cholecystitis, laparoscopic cholecystectomy within 72 hours is recommended. However, a large meta-analysis found no significant difference between early and delayed laparoscopic cholecystectomy in bile duct injury or conversion rates.
For patients with bile duct stones. Guidelines from the American Society for Gastrointestinal Endoscopy ASGE suggest that patients with an intermediate or high probability of developing choledocholithiasis should undergo preoperative or intraoperative evaluation of the common bile duct Figure 2. Figure 2. Management of patients with symptomatic bile duct stones choledocholithiasis.
The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endoscp ; —9 with permission from Elsevier. Several variables predict the presence of bile duct stones in patients who have symptoms Table 4. Patients with associated cholangitis should be given intravenous fluids and broad-spectrum antibiotics.
Biliary decompression should be done as early as possible to decrease the risk of morbidity and mortality. For acute cholangitis, ERCP is the treatment of choice. Patients with acute gallstone pancreatitis should receive conservative management with intravenous isotonic solutions and pain control, followed by laparoscopic cholecystectomy. The timing of laparoscopic cholecystectomy in acute gallstone pancreatitis has been debated.
Studies conducted during the era of open cholecystectomy reported similar or worse outcomes if cholecystectomy was done sooner rather than later.
However, in , Uhl et al 58 reported that 48 of 77 patients admitted with acute gallstone pancreatitis were able to undergo laparoscopic cholecystectomy during the same admission. They concluded laparoscopic cholecystectomy could be safely performed within 7 days in patients with mild disease, whereas in severe disease at least 3 weeks should elapse because of the risk of infection. In a randomized trial published in , Aboulian et al 59 reported that hospital length of stay the primary end point was shorter in 25 patients who underwent laparoscopic cholecystectomy early within 48 hours of admission than in 25 patients who underwent surgery after abdominal pain had resolved and laboratory enzymes showed a normalizing trend, 3.
Rates of perioperative complications and need for conversion to open surgery were similar between the 2 groups. If there is associated cholangitis, patients should also be given broad-spectrum antibiotics and should undergo ERCP within 24 hours of admission. Gallstones are common in US adults.
Abdominal ultrasonography is the diagnostic imaging test of choice to detect gallbladder stones and assess for findings suggestive of acute cholecystitis and dilation of the common bile duct. Fortunately, most gallstones are asymptomatic and can usually be managed expectantly.
In patients who have symptoms or have gallstone complications, laparoscopic cholecystectomy is the standard of care. This article originally appeared in Cleveland Clinic Journal of Medicine. Gallstones: Watch and Wait, or Intervene?
Share this article via email with one or more people using the form below. Advertising Policy. Burke, MD Advertising Policy. Scintigraphy as a second test Acute cholecystitis is primarily a clinical diagnosis and typically does not require additional imaging beyond ultrasonography.
Looking for stones in the common bile duct When acute cholangitis due to choledocholithiasis is suspected, abdominal ultrasonography is a prudent initial test to look for gallstones or biliary dilation suggesting obstruction by stones in the common bile duct.
Watch And Wait, Or Intervene? Asymptomatic gallstones The management of patients with asymptomatic gallstones typically is based on the risk of developing symptoms or complications. Cholelithiasis and cholecystitis. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver ; 6 2 — Diagnosis and treatment of gallstone disease. Practitioner ; — Digestive and liver diseases statistics, Gastroenterology ; 5 — Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases.
In just two years, demand for the laparoscopic approach transformed surgical practice in the United States, and the benefits of the laparoscopic approach were ultimately codified in the new National Institutes of Health NIH guidelines in NOTE: The dashes inserted into the words above are solely for pronunciation assistance and do not appear in the correct spelling of the words.
Columbia University Irving Medical Center. Call us at History of Medicine: The Galling Gallbladder. Learn more about gallbladder disease. He wore a head mirror to reflect light and augment visualization. Also, in , George Kelling, a German surgeon, described "celioscopy " in a dog after peritoneal insufflation with air. Jacobeus of Sweden performed the first human celioscopy in , in a patient with ascitis.
Bernheim from the United States was the first surgeon to publish his experience in laparoscopy entitled "organoscopy" in the Annals Of Surgery, He presented before the German surgical society his 22 years experience with diagnostic laparoscopy. The pioneers of laparoscopy believed that this technique was an important adjunct to surgical practice. Nonetheless, inadequate technology limited their vision, both literally and figuratively.
Light sources, danger of thermal burns to intra-abdominal organs, bowel perforation and vascular injuries posed very real risks and significantly limited the use of laparoscopy. In , Kalk, "father of modern laparoscopy" advocated refinement in the technique through the introduction of the Faroblique degrees lens system, separate pneumoperitoneum needle and a second puncture site.
In , Fourestier, Gladu and Valmiere revolutionized laparoscopy with the introduction of a quartz rod to transmit an intense light beam distally along the telescope enabling photographic images. In , Kurt Semm introduced an automatic insufflator device capable of monitoring intra-abdominal pressure; he also developed thermo coagulation, designed a high-volume irrigation aspiration system, perfected the endoloop applicator, knot-tying techniques and instruments.
He adapted numerous gynaecologic procedures to laparoscopic techniques. Beyond the realm of gynaecologic surgery, he performed omental adhesiolysis, bowel suturing, tumour biopsy and staging, and notably, incidental appendicectomy. By the late s, gynaecologic surgeons had embraced laparoscopy thoroughly. General surgeons remained sceptical and staunchly supported traditional open surgery.
Hasson's introduction of trocar placement under direct vision in cleared much of the doubts among general surgeons who became more receptive to laparoscopic surgery.
On that day in March as he was completing a gynaecologic laparoscopy on a woman also suffering from symptomatic gallstones, he shifted his laparoscope to the subhepatic area.
Upon finding a comparatively free and supple gall bladder he decided to remove it laparoscopically instead of opening up. He performed the procedure successfully and the patient recovered without complications. Finally, in September a NIH consensus conference held in Bethesda concluded that laparoscopic cholecystectomy was the treatment of choice for gall bladder lithiasis. Cholelithiasis and cholecystectomy. Maingot's Abdominal Operations. Prentice Hall International Inc; Vol 2.
Beal JM. Historical perspective of gall stone disease. Surg Gynecol Obstet ; Shehadi WH. The biliary system through the ages. Int Surg ; Leading surgical procedures. Servetus M. O'Malley CD, trans. Christianismi Restitutio and Other Writings.
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