Help your patients navigate gallbladder disease, including asymptomatic stones, incidental polyps, and uncomplicated cholecystitis. Dr. Rahul Pannala (@RahulPannala) talks us through how to diagnose biliary colic, what imaging to order, and what to anticipate for potential post-cholecystectomy complications (eg persistent pain or diarrhea). Feel confident in sending the right patients for cholecystectomy!
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The gallbladder is a reservoir that allows for controlled release of bile into the intestine. The cystic duct connects the gallbladder to the common bile duct which then drains to the duodenum. The biggest driver of gallstones is stasis. Gallstones are common, and there are some risk factors that make them more likely including increasing age, obesity, genetic predisposition, medications (oral contraceptive pills and others), and being on longstanding parenteral nutrition (Bellows 2005).
Biliary colic is caused by intermittent obstruction to the cystic duct. Common bile duct stones tend to cause severe pain and an elevation of liver function tests, gallstones in the cystic duct may be more subtle.
Typical presentation of biliary pain: moderate-severe pain, typically with a crescendo pattern building over time then sometimes waning (but not resolving) then rising again. Typically these episodes last from 30 min- several hours. If you probe, often patients can describe similar (though more mild episodes) prior. Symptoms should not include dyspepsia, bloating, or gas. Nausea is common, vomiting is variable. Location may or may not be helpful- patients may describe diffuse or epigastric abdominal pain, not always classically right upper quadrant abdominal pain. Pain radiating to the back could suggest pancreatic pain or gallbladder pain. In Dr. Pannala’s experience, if the patient is young and describing more of a dyspepsia-type symptom, cholelithiasis is unlikely to be the etiology. (Latenstein 2021)
Typically the exam is normal when a patient presents to clinic after an episode of biliary colic has resolved.
If the patient is presenting in the middle of an episode of biliary colic, the physical exam is very helpful. It is important to evaluate for systemic signs to triage illness severity. The Murphy’s sign is positive when on deep palpation in the subcostal region at the midclavicular line, severe pain is elicited. A positive Murphy’s sign suggests cholecystitis. A sonographic Murphy’s sign can be very predictive as well (ultrasound probe on the gallbladder elicits maximal tenderness) (Ralls 1982).
Labs are typically normal after an episode of biliary colic. If a patient has persistent pain or is presenting to the emergency room, liver function tests (LFTs) are typically checked. If there is LFT elevation, this could suggest more severe disease or choledocholithiasis.
Abdominal ultrasound is the primary test that is most valuable when evaluating biliary colic (Benarroch-Gampel 2011). CT scan is not as sensitive or specific for stones/sludge in the gallbladder. CT is most helpful if the diagnosis is not clear, and can help evaluate for pancreatitis or concern for complications of gallstone disease like a perforated gallbladder (Thomas 2016).
A hepatobiliary iminodiacetic acid (HIDA) scan is helpful in evaluating the patency of the cystic duct in a patient with a less classic presentation. Dr. Pannala recommends this test for evaluating acalculous cholecystitis or bile leaks (for example, a patient post-cholecystectomy who develops severe abdominal pain).
Magnetic resonance cholangiopancreatography (MRCP) is helpful in evaluating a common bile duct stone, depending on the pretest probability of this diagnosis. MRCP is unnecessary for a patient with normal/close to normal liver function tests who is low risk for a CBD stone. For a patient with intermediate risk for CBD stone (ie a mild elevation in bilirubin in the 2 range), an MRCP can be valuable. If a patient has a high bilirubin (ie 4) they have a high probability of a common bile duct stone, and may benefit from endoscopic retrograde cholangiopancreatography (ERCP) (American Society of Gastrointestinal Endoscopy ASGE 2019 Guideline).
In asymptomatic patients, only around 25% will have symptoms or complications from cholelithiasis over a ten year period. Therefore, providers do not need to act on an incidental finding of gallstones. There is no need for cholecystectomy in asymptomatic patients (Sakorafas 2007).
In patients who are symptomatic, at least ⅓ will have ongoing symptoms, approximately 2% per year will have more serious complications like pancreatitis or cholecystitis (Ahmed 2000).
Unfortunately medications are not effective to reduce gallstones.
Eating a moderately low fat diet may reduce symptom flairs. Maintaining a healthy weight can reduce the risk of developing cholelithiasis.
Cholecystectomy is the primary treatment for biliary colic. If a patient is hospitalized with uncomplicated cholecystitis, same-admission cholecystectomy is recommended (Bellows 2005). Uncomplicated cholecystitis does not need treatment with antibiotics, these should be reserved for patients with systemic inflammation or bacteremia.
Post-cholecystectomy diarrhea is very common (around 5-15% of patients (Ahmad 2020)), and can be severe. Diarrhea can be treated with bile acid sequestrants or antimotility agents like loperamide. A low fat diet can be helpful. Post-cholecystectomy diarrhea tends to improve over 3-6 months. Dr. Pannala’s expert approach is to try to wean patients off bile acid sequestrants after 3-6 months because these are complicated medications to take as they need to be spaced out from other medications and taken with food.
Post-cholecystectomy syndrome or post-cholecystectomy pain is common; 40% of patients continue to have pain after surgery. It is important to consider when and how severe this pain is. If this pain is occurring in the short period after surgery, it is important to rule out a bile leak or retained stone. Imaging is likely appropriate depending on the presentation. If the pain is a late presentation, we need to consider functional abdominal pain syndromes. This highlights how important it is to correctly identify symptomatic cholelithiasis from the beginning so the proper patients are selected for surgery (van Dijk 2009).
Biliary sludge should be treated the same as cholelithiasis (Ko 1999).
Gallbladder polyps are common. A polyp <5mm probably does not need further followup. If the patient is older (age >50) and the polyp is larger (>6mm), cholecystectomy is recommended. In any patient, a broad based polyp or polyp >10mm should be removed to reduce the risk of gallbladder cancer. Patients with primary sclerosing cholangitis or other high-risk populations (eg Pima Indians) may be recommended to get removal at smaller sizes or younger age (Grimaldi 1993). In general, gallbladder cancer is rare, but because it is highly morbid, guidelines recommend removal in the above situations (Wiles 2017).
Adenomyomatosis is an inflammatory condition of the gallbladder, often associated with stones. This does not require any treatment or further evaluation (Golse 2017).
Gallstones are common, patients with asymptomatic gallstones do not need a cholecystectomy.
Biliary colic has a typical pattern so it is important to confirm that the abdominal pain your patient is experiencing is truly from gallstones before cholecystectomy.
Ultrasound is the imaging of choice for cholelithiasis.
Listeners will feel comfortable counseling their patients around gallbladder diseases.
After listening to this episode listeners will…
Dr. Rahul Pannala has received funding from Nestle Health Sciences, Blue Star genomics, HCL Technologies, and ERBE USA which are not relevant to the discussion today.
The Curbsiders report no relevant financial disclosures.
Heublein M, Pannala G, Taranto N, Williams PN, Watto MF. “#339 Gallbladder Disease”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list June 13, 2022.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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I have been an avid listener of this podcast for several years, however that is likely to change after listening to episode #340. I am a board certified Internist, with a specialty board in Critical Care. I also happen to be a Board Certified Emergency Medicine physician, I have completed residencies in both IM and EM as well as fellowship in Critical Care. I work clinically in both the ER and ICU, in an academic center. I was extremely disappointed at the comment that Dr. Rahul Pannala made (Min 30 of the podcast), that a patient would inherently receive a CT scan for recurrent biliary colic "Just because they walked into an ER". This is offensive as an Emergency Physician and an embarrassing state coming from a fellow attending Internist. I had hoped that either Dr Paul WIlliams or Dr Molly Heublein would have had the integrity to at least subtly object to such a statement, but sadly it seemed to draw only laughs. I have recommended the 'Curbsiders Podcast' to my IM residents, but now I only feel hypocritical as I am also an avid proponent of professionalism and respect for other specialties. Something I teach my residents, along with clinical education. Based on the response of Dr's Williams and Heublein, it is obvious they agree with this type of unprofessionalism. What I find most ironic is rarely does simple cholecystitis make it onto a medical service - as in the case they describe. The evaluation and care of these patients is almost exclusively handled by the Emergency Physicians and Surgeons. It has been my experience that only complex cases make it to the medical services, in which CT's may have been completed looking for other complications or competing pathologies. Further Dr Rahul Pannala, himself at the beginning of the podcast discusses the wide variation of presentation and locations of pain in cholecystitis. Lastly, as a practicing Emergency Physician, it has been my experience that patients who present with the scenario you have described almost never get CT's.... if you can believe it, we actually order US's, and we actually know they are the test of choice. I continue to be proud to be an Emergency Physician, despite the unprofessionalism and lack of respect my fellow Internists have made the norm.
Hi! We are so sorry that this was an offensive comment to you. It was not meant to be offensive in any way. We're really sorry it came off that way. As always, our focus is practice changing knowledge. We aren’t ever looking to offend anyone. Thank you again for listening to our show.