Armando Hasudungan

Biology and Medicine Tutorials

Gallstone Disease

Overview

  • 75-90% of people with gallstones are asymptomatic, the remainder presents with symptoms because of complications
  • Common gallstones complications include: cholecytitis, cholangitis and choledolithiasis
  • Gallstones are divided into cholesterol (10%), pigment (10%) and mixed stones (80%)
  • Gallstones also are classified by where they are formed:
    • Intrahepatic
    • Galbladder (Cholecystolithiasis)
    • Bile duct (Choledocholithiasis)
  • And by the conditions they cause when impacted:
    • Acute cholecystitis
    • Biliary colic
Definition
Cholelithiasis: gallstones
Choledocholithiasis: presence of stones within the biliary tree
Cholangitis: infection of the common bile duct, usually ascending from gut flora.
Biliary Colic: Temporary obstruction of the cystic or common bile duct by a stone usually migrating from the gall bladder
Acute Cholecystitis: Inflammation of the gallbladder due to obstruction in bile flow
Chronic Cholecystitis: Chronic inflammatory cell infiltration of the gall bladder. Repeated inflammation causes thickening and fibrosis of gall bladder.

Risk factors

  • Cholesterol gallstones occur infrequently in the young and the prevalence increases linearly with age in both gender and approaches 50% at age 70 in women.
  • Diet - Western Diet (e.g high protein, fat, refined carbs, sodium)
  • Rapid weight loss - 50% of obese patients who undergo gastric bypass eventually develop gallstones within 6 months.
  • Biliary sludge
  • Drugs - Estrogens, lipid lowering agents (Statin is protective), Ceftrioxone
  • Lipid Abnormalities
    • Obesity and insulin resistance
    • Diabetes Mellitus
  • Previous surgery (i.e vagotomy or resection of the terminal ileum)
  • Disease involving the distal small bowel (i.e Crohn's disease) - alteration of bile constituents
Remember: Fat, Female, Forty, Fertile, Fair
Remember Older adults are at a higher risk of complications

Protective factors:

  • Statins
  • Ascorbic acid
  • Coffee

Anatomy

normal

Bile and types of stones

Bile Composition

  • Cholesterol
  • Phospholipids
  • Bile pigments (from broken down haemoglobin)
TYPES OF STONES AND THEIR DIFFERENCES
Types of stones Cholesterol Mixed Pigment
Incidence  ~10% 80% ~10%
Morphology Solitary and large Usually multiple, faceted (calcium salts, pigment, and cholesterol) Small, friable and irregular. Black or Brown.
Causes and risk factors Female, Age, Obesity and Admirand's triangle Black pigment stones associated with haemolytic disease. Brown pigment stones associated with hereditary spherocytosis and malaria.

Admirand's triangle: increase risk of stone if decrease lecithin, bile salts and increase cholesterol.

Clinical Presentation

Asymptomatic (75-90% of cases) Gallstones that do not impact do not cause any symptoms. Majority of people have stone that stay in the gallbladder or are to small to cause any problems.

Symptomatic Epigastric/right upper Quadrant pain of the abdomen, radiating to the back. Pain is constant or increasing lasting up to 6 hours. Pain after eating (Food in intestine stimulate CCK release → CCK stimulates gallbladder contraction → PAIN!)

Courvoisier's Law: The presence of jaundice, palpable gallbladder means that the jaundice is unlikely to be due to stones. It is tumour of the head of the pancreas until proven otherwise.

Investigations

Investigations Check FBC, EUC, blood culture, serum amylase and lipase (in acute setting), LFT and serum glucose. Abdominal X-ray can reveal 10% of calculi (radio-opaque calculi). Ultrasound is the procedure of choice as it identifies stones, determine wall thickens and assess ductal dilatation. HIDA scan is useful when ultrasound findings are equivocal.

Remember On ultrasound findings suggestive of an ultrasound echogenic focus (dense) and acoustic shadow

Management

The majority of gallstones are asymptomatic and remain so during a person’s lifetime. Gallstones are increasingly detected as a incidental finding on abdominal radiography or ultrasound scanning.  Over a 10-15 yr period, approximately 20% of these stones will be the cause of symptoms with 10% having severe complications. Once gallstones have become symptomatic, there is a strong trend towards recurrent complications (~30%/yr), often of increasing severity

Asymptomatic: do not require treatment unless risk*

Symptomatic

Initial management is conservative: nil by mouth, IV fluids, opiate analgesia. Surgery is treatment of choice.

Management Surgical treatment is a cholecystectomy. The majority are done laparoscopically, often done as a day case. This is the treatment of choice for all patients fit of general anaesthetics. Indications for chlecystectomy:

  • Symptomatic due to gall bladder stones
  • *Asymptomatic patients with gall stones at risk of complications (diabetics, porcelian gall bladder, history of pancreatitis, long-term immunosuppressed).
Remember Risk of laparoscopic cholecystectomy: conversion to open operation (5-10%), bile duct injury (<1%), bleeding (2%), bile leak (1%)

Management Non-Surgical treatment include percutaneous drainage of gallbladder and dissolution or shock wave lithotripsy which is hardly used.

Complications and Prognosis

Common

Charcots Triad: RUQ pain, WCC/fever, Jaundice
Reynolds Pentad: (Charcot's triad) + altered mental status, hypotension

Uncommon

  • Emphysematous cholecystitis - acute infection of the gallbladder wall caused by gas-forming organisms
  • Cholecytoenteric fistula +/- gallstone ileus
  • Mirizzi's syndrome
  • Porcelain gallbladder
  • Chronic cholecystitis
  • Carcinoma of gallbladder
  • Empyema: abscess in gallbladder
  • Mucocele: stone in neck of gall bladder; bile is absorbed, but mucus secretion continue producing a large, tense globular mass in right upper quadrant.

References

UpToDate
Best Practice
Oxford Handbook Clinical Surgery
Oxford Handbook Clinical Medicine

This section looks at gallstone disease in general. For info on cholecystitis specifically click here.

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