Signs:

• Murphy’s sign: When palpating RUQ, have patient take deep breath simultaneously; Positive sign = cessation of inspiration secondary to pain
• Sonographic Murphy’s: Maximal abdominal tenderness from pressure of the US probe over the visualized gallbladder; Does not have to do with inspiration!
• Courvoisier’s signs: Palpable gallbladder on jaundiced patient
• Porcelain Gallbladder: Calcification of galldbladder thought to be related to chronic cholecystitis; correlated with increased rate of malignancy

Biliary Colic:

• Pathophysiology: pain is due to increased luminal pressure from obstructed gallbladder neck or cystic duct due to stone or sludge 
• Clinical:
• RUQ, epigastric, substernal pain
• Pain can radiate to back or right shoulder 
• Pain is constant despite the name of colic 
• Associated Nausea, Vomiting & Diarrhea
• Gradually resolve after < 6 hours so by the time we them, patient may be pain free; peak pain severity is about 1 hour 
• Why are Gallstones so Important: because of the complications they cause!
• Cholecystitis
• Choledocholithiasis 
• Acute Cholangitis
• Gallstone Pancreatitis
• Gallstone Ileus
• Mirizzi Syndrome: Stone impocated in neck or distal cytic duct that is so large that it compresses the common hepatic duct. 
  

Cholelithiasis:

• Diagnosis:
• Transabdominal Ultrasound: sensitivity ~ 95% for detecting stones > 3 mm; sensitivty drops to ~60 if gallstones are < 3 mm 
• If Transabdominal Ultrasound is negative:
• Repeat US in 1 week if high suspicion negative US (there may be a small stone
• Endoscopic US by GI is another option (indicated when pretest probability is high)
• Management:
• Analgesia: can start with an NSAID such as Toradol 
• Cholecystectomy: will be needed eventually so give patient outpatient surgical referral 

Cholecystitis:

• Prognostication: Tokyo Guidelines
• Provides diagnostic criteria and severity grading for Acute Cholecystitis 
• Hypotensive, AMS, WBC > 18k, Platelets < 100k, INR > 1.5, Cr > 2 = SICK PATIENT 
  
• Management:
• Analgesia, Resuscitation as needed
• Antibiotics: 
• Zosyn
• Cefepime & Flagyl
• Ertapenem
• Consult: Surgery

Choledocholithiasis:

• Primary: formation of stones within Common Bile Duct (CBD)
• Etiology: Biliary Stasis, Cystic Fibrosis
• Secondary: passage of stone from Gallbladder into CBD

Acute Cholangitis