II. Epidemiology
- Cholelithiasis affects 20 million in United States
- Cholecystectomies per year in U.S.: 300,000
- Management complications result in 6000 US deaths/year
- Cholelithiasis Incidence increases with age
- However children have an Incidence of Gallstones of 1.9%
- Females are more often affected after Puberty
- Prior to Puberty, males and females have equal Incidence of Gall Bladder disorders
III. Definitions
-
Biliary Colic
- Transient cystic duct obstruction
- Cholelithiasis
- Presence or formation of Gallstones
-
Acute Cholecystitis
- Persistent obstruction of the cystic duct with constant pain (contrast with Biliary Colic)
- Results in gallbladder wall thickening, serious infection or perforation
-
Choledocholithiasis
- Calculi in the common bile duct
-
Acute Gallstone Cholangitis (Ascending Cholangitis)
- Acute biliary tract infection caused by Bacteria ascending from the Small Intestine
IV. Risks Factors: Cholesterol Gallstones
- Classic 5 F's
- Female
- Forty (age over 40 years)
- Fair skinned (Scandinavian)
- Family History (first degree relative)
- Specific races (e.g. Chilean Indians, Mexican Americans, Pima Indians)
- Fat (Obesity with BMI >30)
- This applies to children as well
- Dietary factors
- High calorie diet
- Excessive intake of refined Carbohydrates
- Low fiber intake
- Prolonged Fasting
- Rapid weight loss (e.g. post-Bariatric Surgery)
- Total Parenteral Nutrition (TPN) Cholestasis
- Common cause in children with serious comorbidity
- Associated Conditions
- Alcoholic Cirrhosis
- Bariatric Surgery
- History of ileal disease, resection or bypass
- Diabetes Mellitus, Metabolic Syndrome or Hyperinsulinism
- Hyperlipidemia (dyslipidemia)
- Obesity
- Pregnancy
- Celiac Disease
- Congenital Causes (esp. Children)
- Sickle Cell Anemia (most common cause in children)
- Hereditary Spherocytosis
- Cystic Fibrosis
- Obesity
- Medications
- Estrogen Replacement (e.g. Premarin)
- Oral Contraceptives
- Ceftriaxone
V. Pathophysiology
- Gall Stones
- Solid calculi form when there is impaired gallbladder motility
- Composition
- Cholesterol stones (80% of Gallstones in U.S.)
- Cholesterol and bile supersaturation which precipitates into Cholesterol monohydrate crystals
- Black pigment stones (20% of Gallstones in U.S.)
- Polymerized calcium Bilirubinate
- Cholesterol stones (80% of Gallstones in U.S.)
- Progression to symptoms
- Gallbladder distention (hydrops)
- Serosal edema
- Infection secondary to obstructed cystic duct
VI. Differential Diagnosis
- Typical right upper quadrant and Epigastric Pain presentations
- Hepatitis
- Hepatic Abscess
- Pancreatitis
- Gastritis
- Peptic Ulcer Disease (perforated or penetrating)
- Gastroesophageal Reflux disease
- Atypical presentations in the abdominal RUQ or epigastric region
- Fitz Hugh-Curtis Syndrome
- Pelvic Inflammatory Disease
- Appendicitis
- Pyelonephritis
-
Chest conditions with radiation into abdominal RUQ or epigastric region
- Right lower lobe Pneumonia
- Myocardial Ischemia or Myocardial Infarction
VII. Types: Gallbladder Disease
VIII. Findings: Symptoms and Signs
- See Biliary Colic
IX. Imaging
X. Management: Approach
- Watchful waiting (expectant management, no intervention) Indications
- Asymptomatic Gallstones (incidentally identified on imaging)
- Pregnancy and symptomatic Gallstones
- Watchful waiting or Cholecystectomy indications
- Symptomatic Gallstones without complications (e.g. Biliary Colic)
- Symptoms resolve in 50% of patients without surgery
- Verhus (2002) Scand J Gastroenterol 37:834-9 [PubMed]
- Symptomatic Gallstones without complications (e.g. Biliary Colic)
-
Cholecystectomy indications
- Recurrent bililary colic
- Acute Cholecystitis
- Cholecystectomy within 72 hours of onset
- Gallstone Pancreatitis
- Cholecystectomy prior to Pancreatitis hospitalization discharge
- Gallbladder Calcification (porcelain gallbladder)
- Risk of gallbladder cancer
- Hemolytic Anemia
- Large Gallstones (>3 cm)
- High risk of gallbladder cancer
- Pending Bariatric Surgery for morbid Obesity
- High risk of symptomatic gallbladder disease related to rapid weight loss
- Native american ethnicity
- Higher risk of gallbladder cancer
- Pending transplant (with Immunosuppression)
- Chronic Immunosuppression risks blunted gallbladder symptoms and increased risk of Ascending Cholangitis
- Gallbladder dysmotility and small Gallstones
- Increased risk of gallstone Pancreatitis
- Pregnancy and recurrent or intractable biliary pain (or associated complications)
- Symptomatic management is preferred
- However Laparoscopic Cholecystectomy is indicated if uncontrolled, persistent symptoms
- Child-Pugh Class A or B Cirrhosis
- Laparoscopic Cholecystectomy is indicated for symptomatic Gallstones (despite the increased complication risk)
- ERCP and Cholecystectomy indications
- Percutaneous cholecystostomy drainage indications (with delayed Cholecystectomy)
- Older or critically ill patients with gallbladder empyema (and associated Sepsis)
XI. Complications
XII. Complications: Post-Cholecystectomy
- See Cholecystectomy
XIII. Course: Asymptomatic Gallstones
- Symptoms developing in Cholelithiasis: 2% per year (average)
- Symptoms within 5 years of diagnosis: 10%
- Symptoms within 10 years of diagnosis: 20%