GI

Gallstone

search

Gallstone, Cholelithiasis

  • 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
  • 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
  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
  • 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
  • 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
  • Findings
  • Symptoms and Signs
  • 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)
  • 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%