Diagnosis of cholelithiasis

Often cholelithiasis proceeds asymptomatically (latent flow is observed in 60-80% of persons with stones in the gallbladder and in 10-20% of individuals with stones in the common bile duct), and concrements are discovered by chance during ultrasound. Diagnosis of cholelithiasis is based on clinical data (the most frequent option in 75% of patients - biliary colic) and ultrasound results.

[1], [2], [3], [4], [5], [6]

Indications for consultation of other specialists

Consultation of the surgeon is necessary in the presence of indications for the operative treatment of cholelithiasis to resolve the question of the method of surgical intervention.

Patients with suspected functional impairment should be referred for counseling to the psychoneurologist.

Plan for examination for gallstones

Careful collection of anamnesis and physical examination (identification of typical signs of biliary colic, symptoms of inflammation of the gallbladder).

Conduction of ultrasound as a priority method or other studies that allow visualization of gallstones. However, even if stones are not available by available methods, the probability of their presence in the common bile duct is assessed as high in the presence of the following clinical and laboratory signs:

• jaundice;
• expansion of bile ducts, including intrahepatic, according to ultrasound;
• altered hepatic samples (total bilirubin, ALT, ACT, gamma-glutamyltranspeptidase, alkaline phosphatase, the latter increases when cholestasis occurs due to obstruction of the common bile duct).

Laboratory testing is necessary to identify persistent obstruction of the bile ducts or the attachment of acute cholecystitis.

One of the important diagnostic purposes should be considered the delineation of the uncomplicated course of cholelithiasis (asymptomatic calcification, uncomplicated colic) and the addition of possible complications (acute cholecystitis, acute cholangitis, etc.), requiring more aggressive medical tactics.

Laboratory diagnostics of cholelithiasis

For uncomplicated course of cholelithiasis, changes in laboratory parameters are not characteristic.

With the development of acute cholecystitis and concomitant cholangitis, leukocytosis (11-15x10 ⁹ / L), an increase in ESR, increased activity of serum aminotransferases, cholestasis enzymes-alkaline phosphatase, y-glutamyltranspeptidase (GGTP), bilirubin level [up to 51-120 μmol / l (3-7 mg%)].

Compulsory laboratory tests

General clinical research:

• clinical blood test. Leukocytosis with a shift of the leukocyte formula to the left is not characteristic of bile colic. It usually occurs when an acute cholecystitis or cholangitis is attached;
• reticulocytes;
• coprogramme;
• general urine analysis;
• blood plasma glucose.

Indicators of lipid metabolism: total blood cholesterol, low density lipoproteins, very low density lipoproteins.

Functional tests of the liver (their increase is associated with choledocholithiasis and bile duct obstruction):

• ACT;
• ALT;
• y-glutamyltranspeptidase;
• prothrombin index;
• alkaline phosphatase;
• bilirubin: general, straight.

Enzymes of the pancreas: blood amylase, urine amylase.

[7], [8], [9], [10], [11], [12], [13]

Additional laboratory tests

Functional tests of the liver:

• serum albumin;
• whey protein electrophoresis;
• timole sample;
• a trialmic test.

Markers of hepatitis viruses:

• HB _s Ag (surface antigen of hepatitis B virus);
• anti-HB _c (antibody to nuclear antigen of hepatitis B);
• anti-HCV (antibodies to the hepatitis C virus).

Enzymes of the pancreas:

• lipase of blood.

[14], [15], [16]

Instrumental diagnosis of cholelithiasis

If there is a clinically valid suspicion of cholelithiasis, first of all, ultrasound should be performed. The diagnosis of cholelithiasis is confirmed using computed tomography (CT), magnetic resonance cholangiopancreatography, ERCP.

Compulsory instrumental research

Ultrasound of the abdominal cavity organs is the most accessible method with high sensitivity and specificity for detection of gallstones: for stones in the gallbladder and the bladder duct, the sensitivity of ultrasound is 89%, specificity - 97%; for stones in the common bile duct - sensitivity less than 50%, specificity 95%. A purposeful search is needed:

• expansion of intra- and extrahepatic bile ducts; concrements in the lumen of the gallbladder and biliary ducts;
• signs of acute cholecystitis in the form of thickening of the gallbladder wall more than 4 mm and revealing the "double contour" of the gallbladder wall.

Survey radiography of the gallbladder area: the sensitivity of the method for detecting bile calculi is less than 20% because of their frequent roentgenogenicity.

FEGS: conducted to assess the state of the stomach and duodenum, examination of the large papilla of the duodenum with suspicion of choledocholithiasis.

[17], [18]

Additional instrumental research

Oral or intravenous cholecystography. A significant result of the study can be considered a "disconnected" gallbladder (extrahepatic bile ducts are contrasted, and the bladder is not detected), which indicates obliteration or blockage of the cystic duct.

CT of abdominal cavity organs (gall bladder, bile ducts, liver, pancreas) with a quantitative determination of the coefficient of weakening of gallstones by Hounsfield; the method makes it possible to indirectly judge the composition of stones by their density.

ERCP is a highly informative method for studying extrahepatic ducts with suspicion of a common bile duct stone or for excluding other diseases and causes of mechanical jaundice.

Dynamic cholescintigraphy makes it possible to assess the patency of the bile ducts in cases where ERCP is difficult to perform. In patients with cholelithiasis, the decrease in the rate of entry of the radiopharmaceutical into the gallbladder and intestine is determined.

Magnetic resonance cholangiopancreatography makes it possible to identify invisible stones in the bile ducts. Sensitivity 92%, specificity 97%.

[19], [20]

Differential diagnosis of cholelithiasis

Yellow colic must be differentiated from the following conditions:

Biliary sludge: sometimes a typical clinical picture of biliary colic is observed. Characteristic of the presence of a yellow sediment in the gallbladder with ultrasound.

Functional diseases of the gallbladder and biliary ducts: they do not find stones at the examination, show signs of a violation of the contractility of the gallbladder (hypo- or hyperkinesia), spasm of the sphincter apparatus according to direct manometry (dysfunction of the sphincter of Oddi). Esophageal pathology: esophagitis, esophagospasm, hernia of the esophageal opening of the diaphragm. Painful sensations in the epigastric region and behind the breastbone are combined with typical changes in PHEGS or X-ray examination of the upper gastrointestinal tract.

Stomach ulcer and duodenal ulcer. Typical pain in the epigastric region, sometimes radiating into the back and diminishing after eating, taking antacids and antisecretory drugs. It is necessary to conduct FEGDS.

Diseases of the pancreas: acute and chronic pancreatitis, pseudocysts, tumors. Typical pain in the epigastric region, irradiating in the back, provoked by eating and often accompanied by vomiting. The diagnosis is helped by the detection of increased activity in the blood serum of amylase and lipase, as well as typical changes in the results of the methods of radiation diagnosis. It should be borne in mind that cholelithiasis and biliary sludge can lead to the development of acute pancreatitis.

Diseases of the liver: typical dull pain in the right subcostal area, irradiating in the back and right shoulder blade. The pain is usually constant (which is not typical for the pain syndrome in biliary colic) and is accompanied by an increase and painfulness of the liver during palpation. Diagnosis is assisted by the determination in the blood of liver enzymes, markers of acute hepatitis and visualization studies.

Diseases of the colon: irritable bowel syndrome, inflammatory lesions (especially when involved in the pathological process of hepatic bending of the large intestine). Pain syndrome is often due to motor impairment. The pain often decreases after defecation or the escape of gases. Distinguish functional changes from organic allow colonoscopy or irrigoscopy.

Diseases of the lungs and pleura. Characteristic manifestations of pleurisy, often associated with cough and shortness of breath. It is necessary to conduct a chest X-ray.

Pathologies of skeletal muscles. Possible pain in the right upper quadrant of the abdomen, associated with movements or the adoption of a certain position. Palpation of the ribs can be painful; Pain can be strengthened by straining the muscles of the anterior abdominal wall.

[21], [22], [23], [24], [25], [26], [27], [28], [29],