Gallstone

Aka: Gallstone, Cholelithiasis

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II. Epidemiology

  1. Cholelithiasis affects 20 million in United States
  2. Cholecystectomies per year in U.S.: 300,000
  3. Management complications result in 6000 US deaths/year
  4. Cholelithiasis Incidence increases with age
    1. However children have an Incidence of Gallstones of 1.9%
  5. Females are more often affected after Puberty
    1. Prior to Puberty, males and females have equal Incidence of Gall Bladder disorders

III. Definitions

  1. Biliary Colic
    1. Transient cystic duct obstruction
  2. Cholelithiasis
    1. Presence or formation of Gallstones
  3. Acute Cholecystitis
    1. Persistent obstruction of the cystic duct with constant pain (contrast with Biliary Colic)
    2. Results in gallbladder wall thickening, serious infection or perforation
  4. Choledocholithiasis
    1. Calculi in the common bile duct
  5. Acute Gallstone Cholangitis (Ascending Cholangitis)
    1. Acute biliary tract infection caused by Bacteria ascending from the Small Intestine

IV. Risks Factors: Cholesterol Gallstones

  1. Classic 5 F's
    1. Female
    2. Forty (age over 40 years)
    3. Fair skinned (Scandinavian)
    4. Family History (first degree relative)
      1. Specific races (e.g. Chilean Indians, Mexican Americans, Pima Indians)
    5. Fat (Obesity with BMI >30)
      1. This applies to children as well
  2. Dietary factors
    1. High calorie diet
    2. Excessive intake of refined carbohydrates
    3. Low fiber intake
    4. Prolonged Fasting
    5. Rapid weight loss (e.g. post-Bariatric Surgery)
    6. Total Parenteral Nutrition (TPN) Cholestasis
      1. Common cause in children with serious comorbidity
  3. Associated Conditions
    1. Alcoholic Cirrhosis
    2. Bariatric Surgery
    3. History of ileal disease, resection or bypass
    4. Diabetes Mellitus, Metabolic Syndrome or Hyperinsulinism
    5. Hyperlipidemia (dyslipidemia)
    6. Obesity
    7. Pregnancy
  4. Congenital Causes (esp. Children)
    1. Sickle Cell Anemia (most common cause in children)
    2. Hereditary Spherocytosis
    3. Cystic Fibrosis
    4. Obesity
  5. Medications
    1. Estrogen Replacement (e.g. Premarin)
    2. Oral Contraceptives
    3. Ceftriaxone

V. Pathophysiology

  1. Gall Stones
    1. Solid calculi form when there is impaired gallbladder motility
    2. Composition
      1. Cholesterol stones (80% of Gallstones in U.S.)
        1. Cholesterol and bile supersaturation which precipitates into Cholesterol monohydrate crystals
      2. Black pigment stones (20% of Gallstones in U.S.)
        1. Polymerized calcium Bilirubinate
  2. Progression to symptoms
    1. Gallbladder distention (hydrops)
    2. Serosal edema
    3. Infection secondary to obstructed cystic duct

VI. Differential Diagnosis

  1. Typical right upper quadrant and Epigastric Pain presentations
    1. Hepatitis
    2. Hepatic Abscess
    3. Pancreatitis
    4. Gastritis
    5. Peptic Ulcer Disease (perforated or penetrating)
    6. Gastroesophageal Reflux disease
  2. Atypical presentations in the abdominal RUQ or epigastric region
    1. Fitz Hugh-Curtis Syndrome
      1. Gonorrhea or Chlamydia perihepatitis
    2. Pelvic Inflammatory Disease
    3. Appendicitis
    4. Pyelonephritis
  3. Chest conditions with radiation into abdominal RUQ or epigastric region
    1. Right lower lobe Pneumonia
    2. Myocardial Ischemia or Myocardial Infarction

VII. Types: Gallbladder Disease

  1. Biliary Colic
  2. Acalculous Cholecystitis (Biliary Dyskinesia)
  3. Acute Cholecystitis
  4. Ascending Cholangitis

VIII. Findings: Symptoms and Signs

  1. See Biliary Colic

IX. Imaging

  1. Gallbladder Ultrasound
  2. HIDA Scan (Hepatobiliary Iminodiacetic Acid Scan)
  3. Magnetic Resonance Cholangiopancreatography (MRCP)

X. Management: Approach

  1. Watchful waiting (expectant management, no intervention) Indications
    1. Asymptomatic Gallstones (incidentally identified on imaging)
    2. Pregnancy and symptomatic Gallstones
  2. Watchful waiting or Cholecystectomy indications
    1. Symptomatic Gallstones without complications (e.g. Biliary Colic)
      1. Symptoms resolve in 50% of patients without surgery
      2. Verhus (2002) Scand J Gastroenterol 37:834-9 [PubMed]
  3. Cholecystectomy indications
    1. Recurrent bililary colic
    2. Acute Cholecystitis
      1. Cholecystectomy within 72 hours of onset
    3. Gallstone Pancreatitis
      1. Cholecystectomy prior to Pancreatitis hospitalization discharge
    4. Gallbladder Calcification (porcelain gallbladder)
      1. Risk of gallbladder cancer
    5. Hemolytic Anemia
      1. Chronic Hemolysis is high risk for formation of black pigmented stones (calcium Bilirubinate Gallstones)
    6. Large Gallstones (>3 cm)
      1. High risk of gallbladder cancer
    7. Pending Bariatric Surgery for morbid Obesity
      1. High risk of symptomatic gallbladder disease related to rapid weight loss
    8. Native american ethnicity
      1. Higher risk of gallbladder cancer
    9. Pending transplant (with Immunosuppression)
      1. Chronic Immunosuppression risks blunted gallbladder symptoms and increased risk of Ascending Cholangitis
    10. Gallbladder dysmotility and small Gallstones
      1. Increased risk of gallstone Pancreatitis
    11. Pregnancy and recurrent or intractable biliary pain (or associated complications)
      1. Symptomatic management is preferred
      2. However Laparoscopic Cholecystectomy is indicated if uncontrolled, persistent symptoms
    12. Child-Pugh Class A or B Cirrhosis
      1. Laparoscopic Cholecystectomy is indicated for symptomatic Gallstones (despite the increased complication risk)
  4. ERCP and Cholecystectomy indications
    1. Choledocholithiasis
  5. Percutaneous cholecystostomy drainage indications (with delayed Cholecystectomy)
    1. Older or critically ill patients with gallbladder empyema (and associated Sepsis)

XI. Complications

  1. Acute Cholecystitis
  2. Choledocholithiasis
  3. Acute Gallstone Cholangitis (Ascending Cholangitis)
  4. Gallstone Pancreatitis

XII. Complications: Post-Cholecystectomy

  1. See Cholecystectomy

XIII. Course: Asymptomatic Gallstones

  1. Symptoms developing in Cholelithiasis: 2% per year (average)
  2. Symptoms within 5 years of diagnosis: 10%
  3. Symptoms within 10 years of diagnosis: 20%

XIV. References

  1. Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
  2. Portincasa (2006) Lancet 368(9531):230-9 [PubMed]

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Related Studies

Ontology: Cholelithiasis (C0008350)

Definition (MSHCZE) Tvorba a přítomnost žlučových kaménků konkrementů v žlučových cestách a žlučníku. Velmi časté onemocnění, které se ve věku nad 50 let vyskytuje v naší populaci u poloviny žen a skoro u třetiny mužů. Příčiny vzniku nejsou do všech podrobností známy, jde zřejmě o poruchu poměru jednotlivých složek žluči. Vliv má nadměrný energetický příjem, dietní návyky, některé nemoci, zánět. Konkrementy mohou být umístěny v žlučníku (cholecystolitiáza) nebo ve žlučovodu (choledocholitiáza). Prokázat je lze zejm. ultrasonografií či rentgenem (cholecystografií, cholangiografií). Klasickými obtížemi jsou žlučníkové záchvaty (biliární koliky) způsobené zablokováním kaménku ve žlučových cestách a zánět žlučníku (cholecystitida). K nejčastějším komplikacím patří městnání žluči (cholestáza) se žloutenkou a zánět žlučových cest (cholangitida). Kaménky lze odstranit operací cholecystektomií, drcením kaménků rázovou vlnou s následným odchodem drobounkých kamínků (litotripsií), endoskopickými metodami (ERCP), ve vybraných případech je též možné rozpouštění kaménků (disoluční léčba žlučovými kyselinami). V mnohých případech nemusí ch. způsobovat vůbec žádné obtíže a může být náhodným nálezem, který nevyžaduje léčbu. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (MSH) Presence or formation of GALLSTONES in the BILIARY TRACT, usually in the gallbladder (CHOLECYSTOLITHIASIS) or the common bile duct (CHOLEDOCHOLITHIASIS).
Definition (CSP) presence or formation of gallstones in the gallbladder.
Concepts Disease or Syndrome (T047)
MSH D002769
ICD9 574
ICD10 K80
SnomedCT 197376000, 266541001, 44900007, 197406002, 197403005, 155823008, 266474003
LNC LA14289-5
English Cholelithiases, Cholelithiasis, BILIARY STONES, CHOLELITHIASIS, Cholelithiasis NOS, cholelith, gallstones, Calculus biliary, Biliary stones, Gall Stones, Gallstones, Biliary Calculi, Gall Stone, Cholelithiasis [Disease/Finding], Gallstones [Disease/Finding], gallbladder calculus, cholecystolithiasis, gallbladder calculus (diagnosis), cholelithiases, calculus of gallbladder, gallbladder stones, gallstone disease, gallstone, Gallstone(s), gallbladder stone, Cholelithiasis NOS (disorder), Biliary calculus (disorder), Stones - gall, Calculus in biliary tract, Stone - biliary, Calculus - biliary, CL - Cholelithiasis, Calculus in biliary tract (disorder), Biliary calculus, cholelithiasis, Gallstone, Biliary calculus, NOS, Cholelithiasis, NOS, Gallstone, NOS, Biliary calculus (disorder) [Ambiguous]
French LITHIASE BILIAIRE, Calcul biliaire, Lithiases vésiculaires, Calculs biliaires, CALCULS BILIAIRES, Lithiase biliaire, Cholélithiase
Spanish COLELITIASIS, CALCULOS BILIARES, Cálculo biliar, Piedras biliares, Piedras en la vesícula biliar, piedra biliar, lito biliar, cálculo biliar (trastorno), colelitiasis, SAI, cálculo biliar, colelitiasis, SAI (trastorno), Cholelithiasis NOS, colelitiasis, cálculo biliar (concepto no activo), cálculo en la vía biliar (trastorno), cálculo en la vía biliar, Colelitiasis
German CHOLELITHIASIS, Gallensteine, Gallenstein, GALLENSTEINE, Cholelithiasis
Portuguese CALCULOS BILIARES, Cálculos biliares, Cálculo biliar, LITIASE BILIAR, Litíase biliar, Colelitíase
Dutch biliaire steen, galstenen, biliaire stenen, cholelithiase, Cholelithiasis, Galstenen
Italian Calcolo biliare, Calcoli biliari, Colelitiasi
Japanese 胆石, 胆石症, ﾀﾝｾｷｼｮｳ, ﾀﾝｾｷ
Swedish Kolelitiasis
Czech cholelitiáza, Cholelitiáza, Žlučový konkrement, Žlučové konkrementy
Finnish Sappikivitauti
Russian ZHELCHNOKAMENNAIA BOLEZN', KHOLELITIAZ, ЖЕЛЧНОКАМЕННАЯ БОЛЕЗНЬ, ХОЛЕЛИТИАЗ
Korean 담석증
Croatian KOLELITIJAZA
Polish Kamica żółciowa
Hungarian Epekövesség, Epekövek, Cholelithiasis, Epekő
Norwegian Kolelitiasis
Derived from the NIH UMLS (Unified Medical Language System)

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