eMedicine Specialties > Gastroenterology > Biliary

Cholelithiasis: Differential Diagnoses & Workup

Author: Douglas M Heuman, MD, FACP, FACG, AGAF, Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Coauthor(s): Anastasios A Mihas, MD, DMSc, FACP, FACG, Professor, Department of Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine; Consulting Staff, Virginia Commonwealth University Hospitals and Clinics; Chief of GI Clinical Research, Director of GI Outpatient Service, Associate Director of Hepatology, Hunter Holmes McGuire Veterans Affairs Medical Center; Jeff Allen, MD, Assistant Professor, Department of Surgery, University of Louisville
Contributor Information and Disclosures

Updated: Aug 25, 2009

Differential Diagnoses

Other Problems to Be Considered

Gallbladder gangrene

Workup

Laboratory Studies

• Patients with uncomplicated cholelithiasis or simple biliary colic typically have normal laboratory test results.
• Acute cholecystitis is associated with polymorphonuclear leukocytosis. In severe cases, mild elevations of liver enzymes may be caused by inflammatory injury of the adjacent liver.
• Choledocholithiasis with acute common bile duct obstruction initially produces an acute increase in the level of liver transaminases (alanine and aspartate aminotransferases), followed within hours by a rising serum bilirubin level. If obstruction persists, a progressive decline in the level of transaminases with rising alkaline phosphatase and bilirubin levels may be noted over several days. Concurrent obstruction of the pancreatic duct by a stone in the ampulla of Vater may be accompanied by increases in circulating lipase and amylase levels.
  • In patients with suspected gallstone complications, blood tests should include a complete blood cell (CBC) count with differential, liver function panel, and amylase and lipase.
  • Repeated testing over hours to days may be useful in evaluating patients with gallstone complications. Improvement of the levels of bilirubin and liver enzymes may indicate spontaneous passage of an obstructing stone. Conversely, rising levels of bilirubin and transaminases with progression of leukocytosis in the face of antibiotic therapy may indicate ascending cholangitis with need for urgent intervention.

Imaging Studies

• Upright and supine abdominal radiographs are occasionally helpful in establishing a diagnosis of gallstone disease.
  • Black pigment or mixed gallstones may contain sufficient calcium to appear radiopaque on plain x-ray films. The finding of air in the bile ducts on plain x-ray films may indicate development of a choledochoenteric fistula or ascending cholangitis with gas-forming organisms. Calcification in the gallbladder wall (the so called porcelain gallbladder) is indicative of severe chronic cholecystitis.
  • The main role of plain x-ray films in evaluating patients with suspected gallstone disease is to exclude other causes of acute abdominal pain, such as intestinal obstruction, visceral perforation, renal stones, or chronic calcific pancreatitis.
• Ultrasonography is the most sensitive, specific, noninvasive, and inexpensive test for the detection of gallstones.
  • Gallstones appear as echogenic foci in the gallbladder. They move freely with positional changes and cast an acoustic shadow.
  • In acute cholecystitis, ultrasonography may demonstrate edema of the gallbladder wall and pericholecystic fluid. Ultrasonography is also helpful in cases of suspected acute cholecystitis to exclude hepatic abscesses and other liver parenchymal processes.
  • Routine ultrasonography is less effective for diagnosing stones in the common bile duct, because the distal bile duct passes behind the duodenum and is hidden from view by intestinal gas. Dilatation of the common bile duct on ultrasonographic images is an indirect indicator of bile duct obstruction but may be absent if the obstruction is of recent onset.
• Computed tomography (CT) scanning is more expensive and less sensitive than ultrasonography for the detection of gallbladder stones. CT scanning is often used in the workup of abdominal pain, as it provides excellent images of all the abdominal viscera. CT scanning is superior to ultrasonography for the demonstration of gallstones in the distal common bile duct.
• Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) has emerged as an excellent imaging study for noninvasive identification of gallstones anywhere in the biliary tract, including the common bile duct (see Image 2 or below). Because of its cost and the need for sophisticated equipment and software, it is usually reserved for cases in which choledocholithiasis is suspected.
  

  

  Magnetic resonance cholangiopancreatography (MRCP) showing 5 gallstones in the common bile duct (arrows). In this image, bile in the duct appears white; stones appear as dark-filling defects. Similar images can be obtained by taking plain radiographs after injection of radiocontrast material in the common bile duct, either endoscopically (endoscopic retrograde cholangiography) or percutaneously under fluoroscopic guidance (percutaneous transhepatic cholangiography), but these approaches are more invasive.

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  Magnetic resonance cholangiopancreatography (MRCP) showing 5 gallstones in the common bile duct (arrows). In this image, bile in the duct appears white; stones appear as dark-filling defects. Similar images can be obtained by taking plain radiographs after injection of radiocontrast material in the common bile duct, either endoscopically (endoscopic retrograde cholangiography) or percutaneously under fluoroscopic guidance (percutaneous transhepatic cholangiography), but these approaches are more invasive.

• Technetium-99m (^99m Tc) hepatoiminodiacetic acid (HIDA) scintigraphy is occasionally useful in the differential diagnosis of acute abdominal pain. HIDA is normally taken up by the liver and excreted into bile, where it fills the gallbladder and can be detected with a gamma camera. Failure of HIDA to fill the gallbladder, while flowing freely into the duodenum, is indicative of cystic duct obstruction. A nonvisualizing gallbladder on a HIDA scan in a patient with abdominal pain supports a diagnosis of acute cholecystitis.
• Endoscopic retrograde cholangiopancreatography (ERCP) permits x-ray imaging of the bile ducts. In this procedure, an endoscope is passed into the duodenum and the papilla of Vater is cannulated. Radiopaque liquid contrast is injected into the biliary ducts, providing excellent contrast on x-ray images. Stones in bile appear as filling defects in the opacified ducts. Currently, ERCP is usually performed in conjunction with endoscopic retrograde sphincterotomy and gallstone extraction.
• Endoscopic ultrasound (EUS) is also an accurate and relatively noninvasive technique to identify stones in the distal common bile duct.
• Laparoscopic ultrasound has shown some promise as a primary method for bile duct imaging during laparoscopic cholecystectomy.⁴ Yao et al were able to evaluate the common bile duct with laparoscopic ultrasound during laparoscopic cholecystectomy in 112 of 115 patients (97.4%) with cholelithiasis. In patients who were categorized preoperatively as having a low probability of bile duct stones, the occurrence rate of stones was found to be 7%; in those who were preoperatively assessed as having an intermediate probability of such stones, the occurrence rate was 36.4%; and in those who were rated with the highest probability of bile duct stones, the occurrence rate was 78.9%.⁴
  
  The investigators suggested that as experience increases with laparoscopic ultrasound, this method may become routine for evaluating the bile duct during laparoscopic cholecystectomy. In addition, Yao et al advised mandatory aggressive preoperative evaluation of the common bile duct in those who are suspected to have an intermediate or high risk of having choledocholithiasis.⁴

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