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Diagnosis and Treatment of Gallstone Diseases SPEAKER Kalpesh Patel, MD

► Kalpesh Patel, MD: No financial relationships to disclose. Off-Label/Investigational Discussion ► In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations.

Learning Objectives Diagnosis and Treatment of Gallstone Diseases Kal Patel, M.D. Assistant Professor of Medicine Section of Gastroenterology & Hepatology Baylor College of Medicine Ben Taub General Hospital Baylor‐St. Luke’s Medical Center Houston, TX

What is a Gallstone? • Gallstone  = solid mix of  1) cholesterol crystals   2) mucin 3) calcium bilirubinate 4) glycoproteins 5) pigments

• Three types – Cholesterol – Pigment – Mixed

• Identify the risk factors and predisposing  conditions associated with gallstone  formation • Diagnose gallstone related conditions  accurately • Evaluate effective treatment of certain  gallstone diseases

Which type of stone is common? • Cholesterol stones – 80‐90% of Western stones – Bile = cholesterol + bile salts + phospholipids – Cholesterol supersatura on → precipita on  of monohydrate microcrystal – Stasis and coalescence of microcrystals in  gallbladder → gallstone

Risk Factors for Gallstone Formation Non‐modifiable

Modifiable

Age Gender Ethnicity Genetics

Pregnancy Weight Loss Drugs/TPN Gallbladder dysmotility Small bowel diseases

Most Common Risk Scenarios Pregnancy During or After

Rapid Weight Loss  Obesity surgery

Venneman NG, van Erpecum KJ. Gastroenterol Clin North Am. 2010 Jun;39(2):171-83

Shaffer EA.Best Pract Res Clin Gastroenterol. 2006;20(6):981-96

What are the clinical gallstone diseases? (And whom to call?) ALL ABOUT THE LOCATION Cholelithiasis : stone  within the gallbladder

SURGERY Choledocholithiasis :  stone within the bile  duct GASTROENTEROLOGY

What Happens in Choledocholithiasis •Migration from gallbladder

Cholelithiasis Complications • Asymptomatic – no treatment • Biliary colic – Intermittent or partial obstruction of the cystic duct – Post prandial right upper quadrant (RUQ) pain associated  with nausea – Gradual onset and relief • Cholecystitis – Persistent cystic duct obstruction leading to inflammation or infection of gallbladder wall – Severe, constant RUQ pain associated with fever, vomiting

Worried about a gallstone – what next? • Numerous testing methods, all influenced by  the pre‐test probability

•Detected in up to 20% •Spontaneous migration : 20% •Complications : 50%  – Colic – Jaundice – Cholangitis – Pancreatitis •Once detected – treat

• First Line:  – Liver Function Tests + Transabdominal Ultrasound

• Results of LFTs and USG + Clinical factors  determine further testing

Test Results in Cholelithiasis Condition

Liver Function Tests

Ultrasound

Normal

Single or multiple  stones within GB Normal CBD

Normal

Single or multiple  stones within GB

Biliary Colic

Cholecystitis

Possibly mild  AST/ALT elevation Severe: Elevated  bilirubin

Murphy’s sign Fluid around GB GB Wall thickening Normal CBD

Time to call a surgeon

Test Results in Choledocholithiasis

What is a HIDA Scan?  (And when to use it) • Cholescintigraphy – technetium labelled  hepatic iminodiacetic acid (HIDA) injected and  excreted into bile • Tracer not seen in gallbladder after 30‐60 mins  >> cystic duct obstruction • Sensitivity 97%, Specificity 90% • Use when cholecystitis is clinically suspected  but ultrasound results are equivocal Richmond BK, DiBaise J, Ziessman H. J Am Coll Surg. 2013 Aug;217(2):317-23

Low risk (0%‐5%)

Intermediate risk (5%‐50%)

High risk (>50%)

Age >55 y Liver  Function  Test

Range

Bilirubin

> 1.8 mg/dL

AST/ALT

Alk  Phos/GGT

Nml – 1000  IU/L

Elevated

Comment

Rarely >15 Rapid rise  and decline

Abnormal in  90‐95%

Normal liver tests Normal common bile duct  (CBD) size on ultrasound

↓ No further evaluation;  consider intraoperative  cholangiogram

CALL SURGEON *** Usually these tests may suggest but not confirm CBD stones – what is next step?

• Diagnostic and therapeutic

Cholangitis

Bilirubin: 1.8‐4 mg/dL

Dilated CBD: >6 mm

Abnormal LFTs other than  bilirubin Pancreatitis

↓ ↓ Evaluate for stone Endoscopic Ultrasound  (EUS) or Magnetic  Cholangiopancreatography  (MRCP)

MRCP • Magnetic resonance cholangiopancreato‐graphy • Performed by Radiology • Non‐invasive, no contrast required

• Limitations: – Altered anatomy – Requires sedation – Risks: • • • •

Pancreatitis: 0‐25% Bleeding Infection Perforation

• Limit use to treatment of likely CBD stone

CBD stone on US Bilirubin: >4 mg/dL

CALL GI

Endoscopic Retrograde CholangioPancreatography • Endoscopic access of the pancreatic and biliary ductal system

Dilated CBD: >6 mm

• Limitations – Contraindications to MRI – Insensitive in non‐dilated ducts and for stones > stricture, stent – Malignant obstruction • Symptoms – – –

• Elevated WBC, abnormal LFTs

Biliary Drainage : Options

Acute Cholangitis : Therapy • Mild Disease – Empiric Antibiotics : 80% will resolve • Biliary excretion:  ampicillin/sulbactam, piperacillin/tazobactam,  quinolones • Anaerobe +/‐ resistant organisms

– Biliary drainage within 24‐48 hours

• Severe Disease ‐ systemic inflammatory response  syndrome (SIRS),  or septic shock – Urgent biliary drainage

• Hospitalize + GI Consult

Fever : 90% RUQ pain                                        Charcot’s Triad Jaundice

• ERCP : ↓ morbidity and mortality compared to percutaneous or  surgery •

ERCP not possible:

• • •

Altered anatomy Unstable for sedation Failed cannulation

– Percutaneous Transhepatic Cholangiography (PTC) • •

Image guided placement of drainage catheter into the intrahepatic duct and then advanced Risks: Bleeding, infection, peritonitis

– Surgery : Common Bile Duct Exploration • •

Open or Laprascopic T‐tube placement

Gallstone Pancreatitis • Gallstones most common cause of pancreatitis in  the U.S. • Impacted small stone at the ampulla >> increased  pancreatic ductal pressures >> extravasation of  pancreatic enzymes • Impacted stone passes into the duodenum in  majority of cases, however, 1/3 recur if  gallbladder remains • AST/ALT > 3 ULN has PPV > 95%

Gallbladder Polyps • Found in up to 5 % of ultrasounds • Typically incidental, however can cause true  biliary pain • Benign vs. malignant – Adenoma vs. hyperplastic (cholesterol,  adenomyomatosis)

• Difficult to distinguish pathology, so rely on  size or presence of symptoms • Combined with stone – increased risk of  cancer

Are there Medications to treat Gallstones? • Bile acids – ursodeoxycholic acid (UDCA) – Reduce biliary cholesterol secretion and increase bile acid  concentration – more soluble

• Most stones mixed with calcium – won’t dissolve • Whom to use UDCA in: – – – –

Small, non‐calcific stones Mild uncomplicated symptoms Good gallbladder function Not surgical candidate

• Long term (> 2 year) use associated with reduction in  symptoms (60 v. 90%) independent of stone dissolution Venneman NG, van Erpecum KJ. Best Pract Res Clin Gastroenterol. 2006;20(6):1063-73

Gallstone Pancreatitis :  Management • Separate Talk – BUT : remember to give adequate IV fluids (300‐ 500 cc/hr)

• Controversies in management of  severe/necrotizing pancreatitis  – Prophylactic antibiotics – Enteral feeding  – Pseudocyst drainage

• Role of early ERCP (within 24‐48 hours) – Associated cholangitis (rising Bilirubin, dilated CBD)

Gallbladder Polyps ‐ Management • Gallbladder polyp (any size) + gallstone – cholecystectomy • Symptomatic (any size) – cholecystectomy • Asymptomatic – >20mm – pre‐op staging + cholecystectomy – 10‐20mm – lap cholecystectomy – 5‐10mm – f/u ultrasound in 3, 6, 12 months and  annual – operate if increasing in size –