Gallstones can cause right upper quadrant pain which can radiate to the right subscapular region (biliary colic) and can follow or fatty meal which stimulates gallbladder contraction.  Very frequently the patient is awakened from sleep early in the morning.  When a gallstone becomes impacted in the neck of the gallbladder a chronic condition becomes acute with persistent pain followed by fever.  The diagnosis is best made with localized tenderness on exam and a right upper quadrant sonogram showing gallstones, a thickened gallbladder wall, and sometimes Pericholecystic fluid.  Only 15% of gallstones are seen on a CT scan therefore a negative CT scan does not exclude the diagnosis, where as 85% of gallstones are seen with ultrasound.  A HIDA scan involving a radioactive dye injected intravenously, is taken up by the liver and excreted into the biliary system where it passively enters the gallbladder.  A positive HIDA scan demonstrates no gallbladder filling since the cystic duct is obstructed.  A condition called biliary dyskinesia has symptoms of vague upper abdominal pain, bloating, nausea, and mild tenderness.  A sonogram shows no gallstones and a HIDA scan shows complete gallbladder filling but abnormal emptying of the gallbladder with a low ejection fraction when cholecysto kinin (which causes gallbladder contraction) is injected likely due to partial cystic duct obstruction leading to chronic gallbladder distention and atony without signs of infection.  Laparoscopic cholecystectomy is recommended.  When gallstones migrate from the gallbladder into the common bile duct and biliary obstruction involving the liver can result in elevated liver function tests.  Infection called cholangitis rapidly causes sepsis as the liver is very vascular and the infection spreads rapidly throoughout the body.  A gallstone can obstruct the distal common bile duct sphincter causing obstruction of the pancreatic duct leading to pancreatitis.  MRI of the biliary system can help detect common bile duct stones.  An ERCP is an endoscopic procedure to go into the common bile duct cut the sphincter and remove stones.  Occasionally when common bile duct stones are found during cholecystectomy a laparoscopic common bile duct exploration can be performed to remove these stones during a laparoscopic cholecystectomy procedure.

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