Generation Gap
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Gallbladder disease is a concern for people above 65. Cholecystectomy, or removal of the gallbladder, is the most common reason elderly people undergo abdominal surgery, partly because the prevalence of gallstones increases progressively with age. At all ages, gallstones are more prevalent in women, occurring in about 16% of women between the ages of 50 and 59 and 31% between the ages of 80 and 89. There are several common manifestations of gallstone disease in elderly patients. These include recurrent pain, infection, gangrene and perforation, pancreatitis, and common bile duct (CBD) stones causing obstruction, jaundice, and possibly infection. The classic presentation of gallstone disease is episodic or colicky pain in the right upper quadrant of the abdomen, starting between 30 and 120 minutes after eating. The pain may radiate to the back or shoulder blade and the patient may have nausea or occasional vomiting. The pain may last from minutes to several hours. Severe prolonged pain or constant pain is a sign of gallbladder infection. Severe epigastric pain radiating to the back may indicate pancreatitis, while the passage of CBD stones can cause excruciating pain that slowly subsides. Many nonspecific symptoms may also be associated with gallbladder disease, especially in the elderly. These include dyspepsia, bloating, indigestion, gassiness, and fatty food intolerance. In addition, elderly patients are more likely to have few or no symptoms until they reach a point of severe infection. Thus, delay in diagnosis is more common in this population. Any clinician caring for elderly patients must have a high index of suspicion for gallbladder disease. A thorough physical examination is important. Jaundice or yellowing of the eyes, is a sign of elevated bilirubin and can indicate CBD stones. Palpation of the abdomen with attention to the right upper quadrant is the most important component of the physical examination. The degree of tenderness can indicate the severity of inflammation or infection of the gallbladder. Guarding or rebound tenderness are signs of peritonitis and may indicate gangrenous or perforated cholecystitis. On the contrary, the examination in an elderly patient can also be misleading and they may not have any signs of peritoneal irritation on examination.
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Springer-Verlag Berlin Heidelberg 2008
Some laboratory tests are important. Elevated white blood cell count is a sign of infection or severe inflammation of the gallbladder. Elevated liver transaminases may be seen in cholecystitis because of irritation of the liver. Elevated bilirubin and alkaline phosphatase are indicators of CBD stones. Amylase and lipase are also checked because they are elevated with gallstone pancreatitis. Combining the history, physical, and laboratory data with imaging tests and possibly endoscopy can make the diagnosis. The most informative test to rule in or out gallstone disease in the elderly is transabdominal ultrasonography of the liver, bile ducts, and gallbladder. Signs of acute cholecystitis include gallbladd
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