[Clinical Notes] Cholelithiasis: Gall Stones History Taking Guide

The Gall stones or Cholelithiasis are very frequently encountered with patients who typically present with epigastric or right upper quadrant pain. The doctor usually make diagnosis immediately based on the symptoms, however, are confirmed by radiological findings suggestive of Cholelithiasis or Gall bladder stones. We will be discussing the very core findings and the approach to Cholelithiasis in this post.

Types of Gall Stones

The first thing to know the causes of Cholelithiasis is, of course the types of Gall stones, so we can identify what etiology may be suspected in the patient. These are as follows:

1. Cholesterol: These are formed due to supersaturation which occurs in obesity, high calorie or patient on Oral contraceptive pills. Other causes include abnormal emptying of gall bladder or Ileal resection.

2. Pigmented Stones: Pigmented or colored stones are again of two types:

Black Stones: Due to hemolysis, could be due to sickle cell anemia, hereditary spherocytosis, etc.)

Brown Stones: Due to bile stasis and infected bile or with foreign bodies such as parasites (ascaris lubricoides), stents.

3. Mixed Stones

Clinical Presentation in Cholelithiasis

Clinical findings in Gall stones are as follows:

  1. Right Upper Quadrant Pain/ Epigastric Pain which may radiate to back. The pain of cholelithiasis is colicky in nature or dull and constant.
  2. Dyspepsia, flatulence, food intolerance particularly to fats, alteration in bowel frequency.
  3. Nausea, vomiting due to biliary colic.

Effects and Complications

  1. Biliary colic
  2. Acute/ Chronic Cholecystitis
  3. Empyema of Gall bladder
  4. Mucocele
  5. Perforation
  6. Biliary obstruction
  7. Acute cholangitis
  8. Acute pancreatitis
  9. Bowel obstruction

It is often a good idea to get a CT scan done if complication occurs. A USG is done to confirm diagnosis. If jaundice occurs, MRCP may be done to exclude Choledocholithiasis.

If resolution doesn’t occurs, then it is followed as:

Empyema > Necrosis and Perforation > Localized peritonitis > Abscess > Abscess may perforate into peritoneal cavity with a septic peritonitis.

Diagnosis and Approach Considerations

Once the clinical suspicion is settled, one can move to radiological findings for final diagnosis as:

  1. Radiological support: USG-CBD, X-Ray, MRCP, MDR-CT, HID Scan, ERCP, PTC, EUS
  2. Murphy’s sign: Right upper quadrant tenderness that is exacerbated during inspiration by examiner’s right subcoastal palpation. (with leukocytosis and with increased LFT)

Important Note

Do check for Courvoiser’s law in the patients of Upper quadrant pain when suspecting gall stone pathology

Courvoiser’s Law: Palpable and Non-tender Gall bladder due to distal CBD (Common Bile Duct) obstruction due to peripancreatic malignancy and not Gall stones.

Treatment and Management of Gall Stones

The patient could present with 3 conditions which are as:

  1. Asymptomatic Gall Stones

  • Nil Per Oral (NPO) and Intravenous Fluids (IVF)
  • Analgesics
  • Broad spectrum antibiotics against Gram negative bacteria such as Cefuroxime, Cefazolin or Gentamicin
  • Subsiding: Oral fluids, then continue regular diet

2. Symptomatic Gall Stones

For Cholelithiasis with symptoms, Cholecystectomy (Open/Laparoscopic) is the choice.

3. Cholelithiasis with Diabetes, Congenital hemolytic anemia or bariatric surgery

Prophylactic Cholecystectomy

We hope the short notes were clear on the topic- Cholelithiasis or Gall Stones. Special thanks to Dr. Pranjal sir for the motivation for the topic.

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