Biliary Tract: Cholelithiasis (Gallstones)

Cholelithiasis (Gallstones)

Basics

  • Overall Gallstone Prevalence in General Population: 7-20%
  • Most Often Remain Asymptomatic or Develop Symptoms Before the Development of Complications
  • Types of Stones:
    • Nonpigmented Stones – Most Common in the US
      • Cholesterol Stones
    • Pigmented Stones – Most Common in the World
      • Black Stones
      • Brown Stones

Cholesterol Stones

  • The Only Nonpigmented Stone
  • Causes:
    • Stasis
    • Increased Water Resorption
    • Low Lecithin Ratio
    • Low Bile Salts
    • High Cholesterol
  • Risk Factors: Mn
    • Female
    • Elderly
    • Pregnancy
    • Obesity
    • Rapid Weight Loss (Common After Gastric Bypass)
    • Diabetes
    • Hispanic or Native American

Black Stones

  • From Excess Unconjugated Bilirubin
    • Interacts with Calcium to Form Calcium Bilirubinate
  • Associated With: TPN, Cirrhosis, Alcoholism, Chronic Hemolysis

Brown Stones

  • Infected Bile Enhances Hydrolytic Enzymes
    • Hydrolysis of Bilirubin forms Insoluble Calcium Salts
  • Found Both Within Gallbladder & Bile Ducts
    • The Predominant de Novo Bile Duct Stone (Cholangiohepatitis)
  • Most Common in Asians

(A) Cholesterol Stone, (B) Mixed Stone, (C) Black Stone 1

Large Gallstone Seen on US 2

Asymptomatic Cholelithiasis

Definition

  • Gallstones Without Any Symptoms

Treatment

  • General Treatment: Nothing

Prophylactic Cholecystectomy Indications

  • Large Stone > 3 cm (Risk for Malignancy)
  • Peds (Unreliable Hx)
  • Liver TXP
  • Sickle Cell Disease (Mimics a Sickle Cell Crisis)
  • Hereditary Spherocytosis (If Already Preforming Splenectomy)
  • Controversial Indications:
    • Concomitant with Gastric Bypass
      • Increased Risk of Stones but Generally ASx
      • Not Indicated if No Stones Are Found
      • Stronger Indication if Concomitant with a Duodenal Switch
    • Spinal Cord Trauma
      • Some Consider a Relative Indication
      • Symptoms Not Necessarily Obscured by Injury

Hydrops Gallbladder

Hydrops Gallbladder

  • Mucus Distention (Bile Absorbed, Mucus Secreted)
  • From Impacted Stone Without Infection
  • Sx: Palpable but Nontender
  • No Increased Risk of Malignancy

Symptomatic Cholelithiasis (Biliary Colic)

Basics

  • Pain from Intermittent Cystic Duct Obstruction by Gallstones
  • “Biliary Colic” is a Misnomer – Pain is Constant for Several Hours (Does Not Wax/Wane)

Presentation

  • Intense Dull RUQ Pain
    • Lasts 30 Minutes-6 Hours
    • Usually Constant, Not “Colicky”
    • Worse After Fatty Meal, Triggering Gallbladder Contraction
  • Associated with Nausea and Vomiting

Treatment

  • Definitive Treatment: Elective Cholecystectomy
  • Medical Option if Refuses Surgery: Ursodeoxycholic Acid (Rarely Used)
    • Dissolution Therapy
    • Only for Symptomatic Small Stones (< 1 cm) with a Functioning Gallbladder
    • 40% Success but 50% Recurrence in 5 Years if Therapy Stopped

Mnemonics

Risk Factors for Gallstones

  • 4 F’s: “Fat Fertile Female in Her Forties”
  • *Some Say “5 F’s” Including “Fair” – This However is Based on the Misconception that Gallstones are Most Common in Caucasians When in Actuality they are More Common in Hispanics & Native Americans

References

  1. Weerakoon H, Navaratne A, Ranasinghe S, Sivakanesan R, Galketiya KB, Rosairo S. Chemical characterization of gallstones: an approach to explore the aetiopathogenesis of gallstone disease in Sri Lanka. PLoS One. 2015 Apr 8;10(4):e0121537. (License: CC BY-4.0)
  2. Nevit Dilmen. Wikimedia Commons (License: CC BY-SA-3.0)