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Cholelithiasis

Cholelithiasis refers to the presence of gallstones in the gallbladder. The majority are cholesterol stones, which form due to cholesterol supersaturation of bile and gallbladder stasis. Pigment and mixed stones are also possible. Gallstones may be asymptomatic or cause biliary colic. Diagnosis involves history, exam, imaging like ultrasound. Treatment options include diet/lifestyle changes, oral dissolution therapy, or cholecystectomy for symptomatic or high-risk cases. Complications can arise if stones obstruct ducts or cause inflammation.

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33 views8 pages

Cholelithiasis

Cholelithiasis refers to the presence of gallstones in the gallbladder. The majority are cholesterol stones, which form due to cholesterol supersaturation of bile and gallbladder stasis. Pigment and mixed stones are also possible. Gallstones may be asymptomatic or cause biliary colic. Diagnosis involves history, exam, imaging like ultrasound. Treatment options include diet/lifestyle changes, oral dissolution therapy, or cholecystectomy for symptomatic or high-risk cases. Complications can arise if stones obstruct ducts or cause inflammation.

Uploaded by

saranya amu
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Definition

Cholelithiasis is the presence of gallstones in the gallbladder

Etiology
Cholesterol stones (80%)

 Precipitates of mostly Cholesterol with bile salts, calcium, and mucin


 Risk factors:
o Obesity
o Rapid weight loss (often after bariatric surgery)
o Diabetes
o Dyslipidemia
o Genetic predisposition
o Pregnancy(impaired Gallbladder emptying caused by progesterone)
o Medications (hormone therapy, oral
contraceptives, ceftriaxone, fibrates, somatostatin analogs)
o Prolonged fasting
o Parenteral nutrition
o Spinal cord injuryPigment stones (10%)

 Caused by excess bilirubin


 Black stones consist of mostly calcium bilirubinate.
 Risk factors:
o Cirrhosis
o Crohn’s disease/ileal resection
o Hemolytic anemias (hereditary spherocytosis, thalassemias, sickle cell disease)
o Advanced age Brown stones ("mixed"; 10%)

 Bacterial infection or parasitic infestation


 Often form in bile ducts
 Most common in Asian populations

Pathophysiology

 Cholesterolstones (3 mechanisms overlap):


o Cholesterol supersaturation of bile
 Hypersecretion of cholesterol (80% from dietary origin)
 Decreased concentration of phospholipids and bile salts
(thatsolubilize cholesterol)→ cholesterol precipitation
o Gallbladder hypomotility (stasis)
 Associated with certain conditions: diabetes, pregnancy, parenteralnutrition
 Cholesterolmicrocrystals are not flushed out effectively→ gallbladdersludge
o Nucleation
 Mucin (secreted by biliary epithelium) promotes crystallization of cholesterolin the sludge.
 Gallstones form and grow larger, further promoted by Gallbladder stasis.
 Black pigment stones:
o Overproduction of bilirubin (hemolysis increases unconjugated bilirubin)
o Decrease in hepatic cycling of bilirubin (cirrhosis)
 Mixed/brown pigment stones:
o Related to infections (bacterial or parasitic infestation, e.g., clonorchiasis)
o Often form in Bile ducts
o Lytic enzymes from bacteria/parasites hydrolyze Bile lecithin→ fatty acids,
which bind calcium
o Calciumsalts + bilirubin + cholesterol → brown stones
 Variant pathology: “porcelain” gallbladder
o Not a gallstone but often found in conjunction with gallstones
o Calcifications in the gallbladder wall, with mechanism felt to be the same as gallstones
o Increased risk of gallbladder cancer

Clinical presentation

 Asymptomatic (80%): Gallstones are found on imaging incidentally.


 Biliary colic:
o Gallstone moves and transiently obstructs the Cystic duct.
o Constant, dull right upper quadrant (RUQ) pain:
 Lasting < 6 hours
 Postprandial or nocturnal
 May radiate to the epigastrium, right shoulder, and back ,Nausea, vomiting

No peritoneal signs

Diagnosis

 History:
o RUQ pain
 Postprandial
 Nocturnal
o Nausea, vomiting, bloating, early satiety
o Risk factors
 Physical exam:
o May have no significant findings
o Mild RUQ tenderness, no peritoneal signs
 Laboratory studies: complete blood count and liver function tests (LFTs) are often normal.
 Imaging:
o RUQ ultrasound (US)
 First test to perform for RUQ pain
 95% specific for detecting stones
 Shows gallstones with posterior acoustic shadow, possible sludge
o Endoscopic ultrasound (EUS)
 If regularultrasound is equivocal or if concurrent stone in the common bile duct(CBD) is
suspected

Can detect very small stones

o Magnetic resonance cholangiopancreatography (MRCP)


 If the ultrasound is equivocal
 If CBD stone is also suspected

Medical management
 Preventive therapy (to prevent symptoms and more stone formation):
o Dietary modification (↓ saturated fat intake; ↑ unsaturated fatty acids, vegetable
protein, vitamin C)
o Weight loss
o Physical activity
 Medical management:
o Manage expectantly; surgical referral when symptoms develop
o Oral litholysis with Bile acids(ursodeoxycholic acid); efficacy is limited, need to take over a
long period of time (> 6 months)
o Nonsteroidal anti-inflammatory drugs (NSAIDs), spasmolytics, anti-nausea medications
(symptom relief)

Surgical management

 Cholecystectomy:
o Definitive treatment when indicated
o Laparoscopic is the standard of care.
o Open surgery for difficult cases and contraindications to laparoscopy
 General indications for surgery:
o Symptomatic (biliary colic) patients
o Asymptomatic patients at risk of gallbladder cancer
 Porcelain gallbladder
 Gallstones > 3 cm
 Gallbladderadenomas
 Anomalous pancreatic ductal drainage
o Asymptomatic patients with hemolytic disorders
o The following asymptomatic patients may benefit from surgery:
 Diabetic Patients due to high risk for complications
 Patientsundergoing bariatric surgery for weight loss
 Complications/risks of surgery:
o CBD injury
o Biliary leaks
o Injury to surrounding organs
o Infection/abscess
o Postcholecystectomy syndrome (bloating, dyspepsia

Complications

Condition Pathology Clinical presentation Laboratory Diagnostic Management


studies imaging

Cholecystitis Cystic duct obstruction Constant RUQ pain (> 6 ↑ WBC US Urgent
with inflammation hours), Murphy’s sign cholecystectomy

Choledocholithiasis Gallstone in CBD Postprandial colicky ↑ Bilirubin, ALP US, MRCP ERCP for stone
causing obstruction RUQ pain > 6 hours; removal →
others: jaundice, acholic cholecystectomy
 Primary: formed stool, dark urine, to prevent
in the bile duct
Condition Pathology Clinical presentation Laboratory Diagnostic Management
studies imaging

 Secondary: pruritus recurrence


gallstone
migration

Acute cholangitis Choledocholithiasis  Charcot’s triad: ↑ WBC, ↑ US, MRCP ERCP → emergent
with infection; with RUQ pain + bilirubin, ALP cholecystectomy
biliary sepsis (E. coli, fever + jaundice
 Reynold’s
Klebsiella,
pentad:
Pseudomonas, Charcot’s triad +
Enterococcus) shock/hypotensi
on + altered
mental status

Gallstone Small stones transiently Epigastric pain, ↑ WBC, ↑ MRCP/CT Delayed


pancreatitis obstructing pancreatic nausea/vomiting amylase/lipase, scan cholecystectomy
duct ↑ bilirubin, ALP

Gallstone ileus Large stone (> 2.5 cm) Small bowel obstruction ↑ WBC CT scan Surgery to extract
passing into the small (diffuse abdominal pain, the stone
Condition Pathology Clinical presentation Laboratory Diagnostic Management
studies imaging

bowel through a nausea/vomiting) (cholecystectomy


cholecystoduodenal not performed in
fistula → obstruction the sam

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