Diagnosis of cholelithiasis

Gallstone disease is often asymptomatic (latent course is observed in 60-80% of people with gallstones and in 10-20% of people with stones in the common bile duct), and stones are discovered accidentally during ultrasound. Diagnosis of gallstone disease is based on clinical data (the most common variant in 75% of patients is biliary colic) and ultrasound results.

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Indications for consultation with other specialists

A surgeon's consultation is necessary if there are indications for surgical treatment of gallstone disease to decide on the method of surgical intervention.

Patients with suspected functional impairments should be referred to a neuropsychiatrist for consultation.

Examination plan for suspected gallstone disease

A thorough history and physical examination (identification of typical signs of biliary colic, symptoms of inflammation of the gallbladder).

Conducting ultrasound as a first-line method or other studies that allow visualization of gallstones. However, even if stones are not detected 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;
• dilation of the bile ducts, including intrahepatic ones, according to ultrasound data;
• altered liver function tests (total bilirubin, ALT, AST, gamma-glutamyl transpeptidase, 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 biliary tract or the development of acute cholecystitis.

One of the important diagnostic goals should be considered the distinction between the uncomplicated course of cholelithiasis (asymptomatic stone carriage, uncomplicated biliary colic) and the addition of possible complications (acute cholecystitis, acute cholangitis, etc.), requiring more aggressive treatment tactics.

Laboratory diagnostics of gallstone disease

For uncomplicated cholelithiasis, changes in laboratory parameters are not typical.

With the development of acute cholecystitis and concomitant cholangitis, the appearance of leukocytosis (11-15x10 ⁹ /l), an increase in ESR, an increase in the activity of serum aminotransferases, cholestasis enzymes - alkaline phosphatase, y-glutamyl transpeptidase (GGT), and bilirubin levels [up to 51-120 μmol/l (3-7 mg%)] are possible.

Mandatory laboratory tests

General clinical studies:

• clinical blood test. Leukocytosis with a shift in the leukocyte formula to the left is not characteristic of biliary colic. It usually occurs with the addition of acute cholecystitis or cholangitis;
• reticulocytes;
• coprogram;
• general urine analysis;
• blood plasma glucose.

Lipid metabolism indicators: total blood cholesterol, low-density lipoproteins, very low-density lipoproteins.

Liver function tests (their increase is associated with choledocholithiasis and biliary obstruction):

• ACT;
• ALT;
• y-glutamyl transpeptidase;
• prothrombin index;
• alkaline phosphatase;
• bilirubin: total, direct.

Pancreatic enzymes: blood amylase, urine amylase.

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Additional laboratory tests

Liver function tests:

• serum albumin;
• serum protein electrophoresis;
• thymol test;
• sublimate test.

Hepatitis virus markers:

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

Pancreatic enzymes:

• blood lipase.

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Instrumental diagnostics of gallstone disease

If there is a clinically justified suspicion of cholelithiasis, an ultrasound scan is first necessary. The diagnosis of cholelithiasis is confirmed by computed tomography (CT), magnetic resonance cholangiopancreatography, and ERCP.

Mandatory instrumental studies

Ultrasound of abdominal organs is the most accessible method with high sensitivity and specificity for detecting gallstones: for stones in the gallbladder and cystic duct, the sensitivity of ultrasound is 89%, specificity is 97%; for stones in the common bile duct, the sensitivity is less than 50%, specificity is 95%. A targeted search is necessary:

• dilation of intra- and extrahepatic bile ducts; stones in the lumen of the gallbladder and bile ducts;
• signs of acute cholecystitis in the form of thickening of the gallbladder wall by more than 4 mm and the detection of a “double contour” of the gallbladder wall.

Plain radiography of the gallbladder area: the sensitivity of the method for detecting gallstones is less than 20% due to their frequent radiolucency.

FEGDS: performed to assess the condition of the stomach and duodenum, to examine the major duodenal papilla if choledocholithiasis is suspected.

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Additional instrumental studies

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 determined), which indicates obliteration or blockage of the cystic duct.

CT of abdominal organs (gall bladder, bile ducts, liver, pancreas) with quantitative determination of the Hounsfield attenuation coefficient of gallstones; the method allows indirectly judging the composition of stones based on their density.

ERCP is a highly informative method for studying extrahepatic ducts when a common bile duct stone is suspected or to exclude other diseases and causes of mechanical jaundice.

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

Magnetic resonance cholangiopancreatography allows to detect stones in the bile ducts that are invisible on ultrasound. Sensitivity 92%, specificity 97%.

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Differential diagnosis of cholelithiasis

Biliary colic must be differentiated from the following conditions:

Biliary sludge: sometimes a typical clinical picture of biliary colic is observed. The presence of bile sediment in the gallbladder during ultrasound is characteristic.

Functional diseases of the gallbladder and bile ducts: examination does not reveal stones, signs of impaired contractility of the gallbladder (hypo- or hyperkinesia), spasm of the sphincter apparatus according to direct manometry (dysfunction of the sphincter of Oddi). Esophageal pathologies: esophagitis, esophagospasm, hernia of the esophageal opening of the diaphragm. Characteristic are pain in the epigastric region and behind the sternum in combination with typical changes in FGDS or X-ray examination of the upper gastrointestinal tract.

Ulcer of the stomach and duodenum. Characterized by pain in the epigastric region, sometimes radiating to the back and decreasing after eating, taking antacids and antisecretory drugs. FEGDS is necessary.

Pancreatic diseases: acute and chronic pancreatitis, pseudocysts, tumors. Typical pain in the epigastric region, radiating to the back, provoked by food intake and often accompanied by vomiting. The diagnosis is aided by detecting increased activity of amylase and lipase in the blood serum, as well as typical changes in the results of radiation diagnostic methods. It should be taken into account that cholelithiasis and biliary sludge can lead to the development of acute pancreatitis.

Liver diseases: characterized by dull pain in the right hypochondrium, radiating to the back and right shoulder blade. The pain is usually constant (which is not typical for pain syndrome in biliary colic) and is accompanied by an enlarged and painful liver upon palpation. The diagnosis is aided by determining liver enzymes in the blood, markers of acute hepatitis, and imaging studies.

Diseases of the colon: irritable bowel syndrome, inflammatory lesions (especially when the hepatic flexure of the colon is involved in the pathological process). Pain syndrome is often caused by motor disorders. The pain often decreases after defecation or gas discharge. Colonoscopy or irrigoscopy help to distinguish functional changes from organic ones.

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

Skeletal muscle pathologies. Pain in the right upper quadrant of the abdomen may be associated with movements or taking a certain position. Palpation of the ribs may be painful; pain may increase with tension of the muscles of the anterior abdominal wall.

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