Cholelithiasis, commonly known as gallstones, and cholecystitis, the inflammation of the gallbladder, are significant conditions that often present in general practice. Here’s a detailed overview:
Causes
- Cholelithiasis (Gallstones):
- Cholesterol Stones: Most common, caused by supersaturation of cholesterol in bile.
- Pigment Stones: Occur due to increased bilirubin (seen in chronic hemolysis, cirrhosis).
- Risk factors: “Five Fs” – Female, Forty, Fertile, Fat, Fair-skinned.
- Cholecystitis:
- Often a complication of cholelithiasis.
- Can also be acalculous (without stones), due to bile stasis and infection.
Diagnosis
- History:
- Biliary Colic: Pain in the right upper quadrant or epigastrium, often postprandial for gallstones.
- Severe, constant pain in the same area for cholecystitis.
- Nausea, vomiting, and intolerance to fatty foods.
- Fever and jaundice (more common in cholecystitis).
- Examination:
- Murphy’s sign (pain or cessation of deep breath with palpation of the right subcostal area).
- Right upper quadrant tenderness.
- Signs of jaundice or fever in cholecystitis.
- Investigations:
- Ultrasound: First-line for detecting gallstones and signs of cholecystitis.
- Blood Tests: Elevated white blood cell count, liver function tests abnormalities.
- CT scan/MRI: Used in complicated cases or if ultrasound is inconclusive.
Differential Diagnosis
- Peptic Ulcer Disease: Epigastric pain, relation to meals.
- Hepatitis: Jaundice, liver function test abnormalities.
- Pancreatitis: Epigastric pain radiating to the back, elevated lipase/amylase.
- Right Lower Lobe Pneumonia: Cough, fever, respiratory symptoms.
Management
- Conservative Treatment:
- Fasting, intravenous fluids, analgesia for acute episodes.
- Antibiotics if infection is suspected.
- Surgical Treatment:
- Cholecystectomy: Standard treatment for symptomatic gallstones and cholecystitis.
- Laparoscopic approach is preferred.
- Diet and Lifestyle:
- Low-fat diet.
- Weight management and regular exercise.
- Medication:
- For gallstones, ursodeoxycholic acid can dissolve cholesterol stones but is rarely used due to the high recurrence rate and need for long-term treatment.
- Follow-up and Monitoring:
- Post-surgical follow-up for complications.
- Educate about signs of complications like bile leaks, infections.
- Special Considerations:
- Management in pregnant women and elderly patients might differ.
- Consider comorbidities while planning treatment.
- Patient Education
- Importance of follow-up care.
- Recognizing symptoms of complications.
- Dietary recommendations to prevent recurrence.
- Referral
- Gastroenterologist or General Surgeon consultation for surgical management.
- Consider referral in complicated cases or if diagnostic uncertainty persists.
It’s essential for any management plan to be tailored to the individual patient, considering their overall health, comorbidities, and preferences. Regular follow-up is crucial to monitor for any complications or recurrence of symptoms.