The most common disorders affecting the gallbladder are consequences of gallstone formation. Gallstones are extremely common, occurring in up to 50% of women in their 70s. Factors associated with an increased risk of gallstone disease include being female, increasing age, race, with highest rates in Native Americans, Hispanics, and whites, obesity, Crohn’s disease, pregnancy, occurrence in other family members, and rapid weight loss. The majority of patients with gallstones are asymptomatic. When symptoms do occur, patients most commonly present with biliary colic (pain in the cystic duct that drains the liver) or with acute cholecystitis (inflammation of the gallbladder).
Biliary colic results from continued contraction of the gallbladder while there is a stone in the cystic duct. Patients complain of pain, usually in the right upper quadrant or epigastrium (area over the stomach). The pain is classically described as being triggered by fatty foods, but pain may also occur with other foods or without a clear relationship to meals. The pain is constant, and may last from about 30 minutes to a few hours. In addition to pain, patients often complain of indigestion, bloating or belching, and nausea. Physical examination is usually unremarkable as are laboratory studies. After an initial attack about 50% of patients will suffer another attack within 1 year, while about 25% will be asymptomatic over the next 10 years.
Acute cholecystitis results from complete obstruction of the cystic duct, which then leads to inflammation of the gallbladder. The pain of acute cholecystitis usually starts more insidiously, with vague abdominal discomfort. As the degree of inflammation in the gallbladder increases, the peritoneum becomes inflamed and the pain localizes to the right upper quadrant or epigastrium. Unlike biliary colic, the pain persists and worsens over time. Patients may report radiation of the pain to the back or the right shoulder, or may describe the pain as “belt” like. Associated nausea and vomiting are common. Fever is also a frequent finding. On physical examination the right upper quadrant is tender, often with guarding and local peritoneal signs (marked tenderness upon touching the abdomen). A positive Murphy’s sign, which is the sudden halt to inspiration with palpation of the right upper quadrant, is common. A mass or fullness may be appreciated, although this may be difficult to feel due to the tenderness of the abdomen. Laboratory studies usually reveal an increased white blood count.
The best imaging study for gallstone disease is ultrasonography. Ultrasound is more than 98% sensitive and more than 95% specific for gallstones. Sludge in the gallbladder may also be identified and can cause biliary colic. Ultrasound findings consistent with acute cholecystitis include thickening of the gallbladder wall and pericholecystic fluid (fluid around the gallbladder). Ultrasound can also show dilation of the biliary tree, which may result from obstruction of the common bile duct by a stone or a mass. Computed tomography is not nearly as sensitive or specific as ultrasound in diagnosing gallstones, although inflammatory changes around the gallbladder may be evident in acute cholecystitis. Biliary scintigraphy (also known as a “HIDA scan”—a test using radiolabeled material to image the gallbladder and associated structures) will show nonvisualization of the gallbladder in patients with acute cholecystitis due to gallstones.
The clinical scenario dictates treatment of gallstone disease. Patients with asymptomatic gallstones require no treatment since only about 10-20% of patients will develop symptoms. Several modalities have been described for dissolving gallstones. The bile salts chenodeoxycholic acid or ursodeoxycholic acid can be administered orally and, over the course of 6-12 months, can lead to complete dissolution of cholesterol stones, but up to 50% of patients will develop recurrent stones within 1 year. This modality may be considered for poor operative candidates. Direct dissolution and shock wave lithotripsy are considered experimental in the United States.
Patients with a single episode of biliary colic (gallbladder pain) may be observed. Recurrent episodes of colic tend to become more frequent and severe with time, so in these patients cholecystectomy (removal of the gallbladder) should be considered. Cholecystectomy is usually performed laparoscopically on an outpatient basis. Morbidity and mortality rates are low and most patients return to normal activities within a week or two.
Patients with acute cholecystitis should be admitted to the hospital for intravenous antibiotics. Cholecystectomy is usually performed within 24-48 hours. Patients who are poor operative candidates can be managed with antibiotics alone with success. However, in the presence of a palpable gallbladder or abnormal liver function tests nonoperative therapy usually fails. Persistence or worsening of fever or elevation in the white blood cell count despite antibiotic treatment are indications for immediate surgery. In most cases laparoscopic cholecystectomy will be successful. Conversion to open cholecystectomy is more likely in patients with acute cholecystitis.
While most patients report no consequence from cholecystectomy, some will complain of increased bloating or abdominal discomfort particularly with eating. These symptoms usually resolve with time.
Biliary colic can occur without gallstones. Biliary dyskinesia (abnormal contractions of the biliary tract) is an uncommon motility disorder of the gallbladder. Measuring a gallbladder ejection fraction using biliary scintigraphy makes the diagnosis. Cholecystectomy is indicated, although not all patients will have complete pain relief.
Other diseases of the gallbladder are quite uncommon. Polyps are occasionally identified on ultrasonography. In most cases cholecystectomy is indicated, although the incidence of progression to cancer appears to be small. Carcinoma of the gallbladder is rare and carries an extremely poor prognosis.