A 79 y.o. non English speaker comes to the ED with nausea, vomiting and hypotension.
What do you see?
Our patient had a gallstone blocking the common duct.
10-15% of the world’s population develop gallstones. Most of these, 80%, are asymptomatic. Of the 20% that are symptomatic, only 4% develop painful biliary colic. A gallstone is primarily made of layers of cholesterol, bilirubin, calcium and protein. Stones that are primarily cholesterol are yellow and pigment stones made primarily of bilirubin are dark.
a yellow cholesterol stone and dark pigment stones.
US is the best first test for gallstones because they can be missed on CT. They can also be missed on ultrasound especially if they are in a biliary duct. MRCP( magnetic resonace cholangiopancreatography) can be used to better visualize the bile ducts. Another common test is a HIDA(hepatobiliary iminodiacetic )scan in which a tracer that mimics bilirubin is injected intravenously and is taken up and secreted in bile. The HIDA scan tests the function of the gallbladder and biliary system and can identify chronic cholecystitis.
While gallstones can be painful or asymptomatic, there are long-term sequellae of stones. Chronic cholecystitis can lead to cancer and chronically infected stones cause a nidus of infection which can lead to sepsis. Typhoid Mary shed Salmonella typhi from her gallstones and repeatedly infected people after refusing surgery.
Surgery is not without risk. Dropped gallstones during laparascopic chole can lead to abdominal abscesses. In addition, recurrent stones in the common duct after gallbladder removal are well documented. A dumping syndrome occurs in 20% of people who have their gallbladder removed because bile has a laxative effect.
WHO IS AT RISK?
1. Women-estrogen either in birth control pills or during pregnancy causes increased in the ratio of cholesterol to bile salts.
2. Obese individuals- obesity causes higher levels of cholesterol in the bile and decreased gallbladder emptying.
3. Individuals with a genetic predisposition- American Indians ( both Pima and Mexican) are at risk with 40% of the population receiving a cholecystectomy by age 85
4. Individuals with . hemolytic anemia- Patients with sickle cell anemia, porphyria, or autoimmune hemolysis are at risk for pigment stones with larger amounts of bilirubin in the bile.
5.Individuals on GLP-1 receptor agonists- Studies have shown weight loss drugs double the risk of gallstones. These drugs inhibit gallbladder motility and delay emptying allowing gallstones to form.
Our patient was treated with broad spectrum antibiotics. She had a esophago-jejunal anastamosis from a previous Roux-en-Y which made ERCP impossible. A percutaneous drain was placed and she was weaned from antibiotics. She was discharged to follow up in her home country.
Mansour S, Kluger Y, Khuri S. Primary recurrent common bile duct stones:timing of surgical intervention. J Clin Med Res 2022Nov;14(11):441-447.
https://en.wikipedia.org/wiki/Gallstone
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