cholelithiasis (gallstones)
Jump to navigation
Jump to search
Introduction
Gallstones. The presence of concretions in the gallbladder or bile ducts[1].
Classification
2 types of gallstones
- cholesterol (white, 70%)
- bile (pigmented, 30%)
Etiology
- physical activity may reduce risk of symptomatic gallstones[15]
- disorders of hemolysis associated with pigment gallstones associated with development of bile (pigmented) stones[17]
- sickle cell anemia
- hereditary spherocytosis
- beta-thalassemia
- cirrhosis -> portal hypertension ->splenomegaly
- Crohn's disease*, ileal resection, & other ileal diseases decrease bile salt reabsorption & increase risk for gallstones
* ulcerative colitis not associated with increased risk for gallstones[17]
Epidemiology
- women are more likely to develop cholesterol gallstones than men, especially during reproductive years
- more common in mutiparous women
Pathology
- estrogen increases biliary cholesterol secretion
- progesterone reduces gallbladder contractility
Genetics
Clinical manifestations
- most patients asymptomatic
- risk of developing symptoms is 1-2%/year
- biliary colic is the most common clinical presentation of symptomatic patients[4]
- right upper quadrant pain with residual soreness after eating
- fever
- nausea/vomiting
- intolerance to dietary fat
- flatulence (no association)[17]
Laboratory
- serum alkaline phosphatase may be elevated with
- occasionally elevated serum bilirubin &/or urine bilirubin
Diagnostic procedures
- ERCP prior to cholecytectomy may be needed to decompress bile duct & prevent cholangitis
- cholecystectomy with intraoperative cholangiography followed by ERCP if common bile duct stones identified[10]
Radiology
- abdominal ultrasound is test of choice
- Loincs: US of biliary ducts & gallbladder, US of gallbladder
- findings
- thickened gallbladder wall
- gallstones
- pericholecystic fluid[4]
- common bile duct dilation
- may be absent if obstruction of recent onset[17]
- 10% of stones may be demonstrated with plain films of abdomen
- abdominal CT useful for detection of intrahepatic stones or recurrent pyogenic cholangitis
- MRI for common bile duct stones[5]
- 99m Tc HIDA scan may be useful
- diagnosis of cystic duct obstruction.
Complications
- complications preceded by episode of biliary colic[4]
- risk factors:
- significant complications occur rarely in asymptomatic individuals
- < 20% of patients with incidentally discovered gallstones experience & clinical event[11]
- < 1/2 of these events are complicated[11]
- multiple stones & larger stones more likely associated complications[11]
- cormorbid illness do NOT increase the risk of complications[11]
- choledocholithiasis with common bile duct obstruction & cholangitis
- stones in the common bile duct commonly, impact distally in the ampulla of Vater[17]
- pancreatitis
- ileus
- gallbladder empyema & perforation
- in patients who have undergone cholecystectomy, retained common bile duct stones may complicate the postoperative course
Management
- asymptomatic cholelithiasis is a common incidental finding for which no specific therapy is generally necessary[4]
- observation & analgesics for uncomplicated symptomatic gallstones provide pain relief similar to that of cholecystectomy[21]
- cholecystectomy
- indications
- cholecystitis, biliary colic
- gallstones > 3 cm to prevent gallbladder cancer[4]
- gallbladder polyps > 1 cm[4]
- not indicated for asymptomatic cholelithiasis
- predictors of benefit for cholecystectomy include
- older age, no history of abdominal surgery, pain radiating to back, nausea, no heartburn[20]
- laparoscopic cholecystectomy
- generally the procedure of choice
- less morbidity than open cholecystectomy
- open cholecystectomy
- routine pre-operative ERCP is not indicated
- cholecystectomy without ERCP for patients with moderate risk of common bile duct stone[10]
- indications
- ursodiol
- indicated for small (< 2 cm) CT radiolucent, non-calcified gallstones in patients with high surgical risk
- dissolves 30-50% of stone (< 2 cm) in 18-24 months
- recurrence rate is > 50%
- useful for prevention of gallstone formation in patients on rapid weight-loss programs
- NOT useful for delaying cholecystecomy in patients with symptomatic gallstones[6]
- NOT useful for low risk asymptomatic gallstones[4]
More general terms
More specific terms
Additional terms
References
- ↑ 1.0 1.1 Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 363
- ↑ DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 874
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021.
- ↑ 5.0 5.1 Journal Watch 25(15):118, 2005 Moon JH, Cho YD, Cha SW, Cheon YK, Ahn HC, Kim YS, Kim YS, Lee JS, Lee MS, Lee HK, Shim CS, Kim BS. The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US. Am J Gastroenterol. 2005 May;100(5):1051-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15842578 Hallal AH, Amortegui JD, Jeroukhimov IM, Casillas J, Schulman CI, Manning RJ, Habib FA, Lopez PP, Cohn SM, Sleeman D. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis. J Am Coll Surg. 2005 Jun;200(6):869-75. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15922197 Kim YJ, Kim MJ, Kim KW, Chung JB, Lee WJ, Kim JH, Oh YT, Lim JS, Choi JY. Preoperative evaluation of common bile duct stones in patients with gallstone disease. AJR Am J Roentgenol. 2005 Jun;184(6):1854-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15908542
- ↑ 6.0 6.1 Venneman NG, Besselink MG, Keulemans YC, Vanberge-Henegouwen GP, Boermeester MA, Broeders IA, Go PM, van Erpecum KJ. Ursodeoxycholic acid exerts no beneficial effect in patients with symptomatic gallstones awaiting cholecystectomy. Hepatology. 2006 Jun;43(6):1276-83. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16729326
- ↑ Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci. 2007 May;52(5):1313-25 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17390223
- ↑ Lammert F, Miquel JF. Gallstone disease: from genes to evidence-based therapy. J Hepatol. 2008;48 Suppl 1:S124-35 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18308417
- ↑ Wittenburg H. Hereditary liver disease: gallstones. Best Pract Res Clin Gastroenterol. 2010 Oct;24(5):747-56. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20955975
- ↑ 10.0 10.1 10.2 Iranmanesh P et al. Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: A randomized clinical trial. JAMA 2014 Jul; 312:137 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25005650
- ↑ 11.0 11.1 11.2 11.3 11.4 Shabanzadeh DM et al. A prediction rule for risk stratification of incidentally discovered gallstones: Results from a large cohort study. Gastroenterology 2016 Jan; 150:156 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26375367
- ↑ Gracie WA, Ransohoff DF. The natural history of silent gallstones: the innocent gallstone is not a myth. N Engl J Med. 1982 Sep 23;307(13):798-800. PMID: https://www.ncbi.nlm.nih.gov/pubmed/7110244
- ↑ Othman MO, Stone E, Hashimi M, Parasher G Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits. Gastrointest Endosc. 2012 Sep;76(3):564-9. Epub 2012 Jun 23. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22732875
- ↑ Banim PJ, Luben RN, Bulluck H et al The aetiology of symptomatic gallstones quantification of the effects of obesity, alcohol and serum lipids on risk. Epidemiological and biomarker data from a UK prospective cohort study (EPIC-Norfolk). Eur J Gastroenterol Hepatol. 2011 Aug;23(8):733-40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21623190
- ↑ 15.0 15.1 Banim PJ, Luben RN, Wareham NJ et al Physical activity reduces the risk of symptomatic gallstones: a prospective cohort study. Eur J Gastroenterol Hepatol. 2010 Aug;22(8):983-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20130468
- ↑ Chen YY, Chen CC Cholelithiasis N Engl J Med 2017; 377:371. July 27, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28745992 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMicm1612408
- ↑ 17.0 17.1 17.2 17.3 17.4 17.5 Shalkow J Fast Five Quiz: Test Your Knowledge of Gallstones Medscape. June 12, 2018 https://reference.medscape.com/viewarticle/897845
- ↑ Demehri FR, Alam HB. Evidence-Based Management of Common Gallstone-Related Emergencies. J Intensive Care Med. 2016 Jan;31(1):3-13. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25320159
- ↑ Warttig S, Ward S, Rogers G; Guideline Development Group. Diagnosis and management of gallstone disease: summary of NICE guidance. BMJ. 2014 Oct 30;349:g6241. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25360037
- ↑ 20.0 20.1 Latenstein CSS, Hannink G, van der Bilt JDW et al. A clinical decision tool for selection of patients with symptomatic cholelithiasis for cholecystectomy based on reduction of pain and a pain-free state following surgery. JAMA Surg 2021 Aug 11; 156:e213706. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34379080 PMCID: PMC8358816 (available on 2022-08-11) https://jamanetwork.com/journals/jamasurgery/article-abstract/2782931
- ↑ 21.0 21.1 Ahmed I et al. Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): Pragmatic, multicentre randomised controlled trial. BMJ 2023 Dec 6; 383:e075383. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38084426 PMCID: PMC10698555 Free PMC article https://www.bmj.com/content/383/bmj-2023-075383
- ↑ Gallstones https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones
- ↑ Dieting and Gallstones https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones/dieting
Patient information
cholelithiasis (gallstones) patient information