Bitter images: Gallbladder disease

“BitterSweet” was the theme of the 20th KHM Continuing Education Conference 2018. In a keynote lecture, Prof. Stephan Vavricka, MD, and Regula Capaul, MD, presented five pathologies of the gallbladder based on real case examples.

The first case was that of a patient who had been diagnosed with a solitary gallbladder polyp in 2016. Initially it had a size of 4 mm, but now – with accompanying wall thickening – it was over 10 mm in size. The S3 guideline of the DGSV recommends cholecystectomy in these cases (polyp ≥1 cm) [1]. This is the sound barrier, emphasizes gastroenterologist Prof. Stephan Vavricka, MD. Studies show that the probability of developing carcinoma is up to 50% higher for solitary polyps ≥1 cm [2]. However, gallbladder polyps are usually benign, with 60% being cholesterol polyps. This so-called “strawberry gallbladder” differs from the gallstone in that it does not form a sonic shadow and does not change  position when rearranged. The second most common form of benign polyp formation is adenomyomatosis, which occurs predominantly in women and is often associated with gallstones. It is still unclear to what extent adenomyomatoses contribute to malignant developments. Although adenomas are relatively rare (4%), they represent a potential danger, especially since adenoma carcinoma is the most common malignant polyp form (80%) (Table 1) . In principle, if the polyp is <1 cm, follow-up should be performed at six months instead of cholecystectomy, and if there is no growth, sonographic monitoring should be performed annually for five years [1]. If it is larger, surgical removal is indicated, especially if size progression is accompanied by a thickened gall wall and gallstones. Due to the low mortality incidence, patients can be recommended laparoscopic cholecystectomy without any problems [3]. This early measure with critical polyp size prevents the development of gallbladder carcinoma, which tends to occur rarely, but then, due to late diagnosis, can rapidly become lethal; patients >50 years of age are particularly affected, and the incidence is four times higher in women.

Cholecystolithiasis (gallbladder stones) is also 1.5-3 times more common in women than in men, depending on age. The risk increases with age [4]. Biliary symptoms include persistent colicky pain in the epigastrium or right upper abdomen for longer than 15 minutes, which may radiate to the right shoulder, and nausea. Since CT and MRI miss gallstones in about 20% of cases, sonography is the primary diagnostic tool thanks to a sensitivity of >95% [1]. However, cholecystolithiasis may also be asymptomatic and diagnosed by chance. Seven studies show that cholecystectomy is not useful for asymptomatic cholecystolithiasis: 60-80% of the total 823 patients observed remained asymptomatic over the study period of 2-25 years. The likelihood of developing biliary symptoms is 2-4% in the first five years after diagnosis and decreases to approximately 1-2% in subsequent years [1]. There are three exceptions to this rule:

• In the presence of a porcelain gallbladder (calcification of the gallbladder wall), surgery should be performed due to the risk of developing gallbladder carcinoma (risk up to 20%).
• If gallstones have a size of >3 cm, cholecystectomy is indicated because malignant inflammation may develop. In men, the risk of gallbladder carcinoma is increased nine- to tenfold.If polyps >1 cm are also present, cholecystectomy should be performed regardless of symptoms.

Emergency cholecystectomy is indicated in cases of acute cholecystitis: Here, there is a risk of perforation and severe abscess formation. If the history is delayed by days, therapy consists primarily of administration of antibiotics before cholecystectomy can be performed at a later time. Nevertheless, such cases should be referred to a surgical emergency department for evaluation.

Cholestatic hepatopathies include primary biliary cholangitis (PBC), which affects 80-90% men, and primary sclerosing cholangitis (PSC), which is a disease of 60-80% women. Clinical suspicion of primary biliary cholangitis is raised by pruritus, chronic fatigue, hepatomegaly, furthermore steatorrhea and xanthelasmas. Serological diagnostic criteria are AP levels elevated more than one and a half times the norm and elevated AMA levels (AMA-M2 >1:40). A possible liver biopsy can exclude comorbidities such as autoimmune hepatitis and nonalcoholic steatohepatitis. Due to the large number of possible associated diseases (Tab. 2) , Prof. Vavricka recommends actively searching for other comorbidities, e.g. by means of sprue serology or the clarification of possible joint pain.

Primary sclerosing cholangitis predominantly affects the small bile ducts and often manifests intrahepatically. Again, AP values are significantly elevated (3× ULN). Elevated titers for ANCA may also indicate the presence of PSC. In the context of diagnosis, imaging is goal-directed. MRCP is recommended as the primary diagnostic tool. While ERCP is still considered the gold standard, there is a risk of post-ERCP pancreatitis, which is why Prof. Vavricka urges caution with this imaging procedure. Another option is liver biopsy, where PSC is seen in an onion-skin-like walling of the bile ducts. Like PBC, PSC is often associated with other diseases. Comorbidities with inflammatory bowel disease are found in 80% of cases. Therefore, it is worthwhile to perform colonoscopy in PSC patients. Thus, 87% of PSC patients are also affected by ulcerative colitis [5]. These patients should be screened regularly because of the greatly increased risk of tumors.

The diagnosis of choledocholithiasis (bile duct stones) varies depending on the risk level (Table 3). If liver function values and bile duct size are normal, no further clarification is required. A medium risk exists if the patient is already older and further complications such as a dilated bile duct, elevated bilirubin levels, cholecystolithiasis, etc. are present. Then, a more in-depth analysis by endosonographic ultrasonography (EUS) or MRCP is indicated. First-line diagnostic tool is EUS. If the suspicion of bile duct stones is confirmed, ERCP is performed. In view of possible side effects, ERCP should only be performed as soon as the risk of bile duct stones is more than 50% or when the risk of bile duct stones is less than 50%. cholangitis is suspected.

Cholangitis, the inflammation of the gallbladder and bile duct due to obstruction of the bile ducts, is a dreaded consequence of choledocholithiasis, as it is particularly common in patients with chronic gallbladder disease. quickly becomes life-threatening for elderly patients. One indication is a sharp rise in transaminases. Diagnosis is difficult in cases of intermittent obstruction due to “migrating” bile duct stones.

Source: 20th Continuing Education Conference of the College of Family Medicine (KHM), June 21-22, 2018, Lucerne.

Literature:

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HAUSARZT PRAXIS 2018; 13(8) – published 7.7.18 (ahead of print).