GI
Gallstone
search
Gallstone
, Cholelithiasis
See Also
Biliary Colic
Acute Cholecystitis
Choledocholithiasis
Acute Gallstone Cholangitis
(
Ascending Cholangitis
)
Acalculous Cholecystitis
Epidemiology
Cholelithiasis affects 20 million in United States
Cholecystectomies per year in U.S.: 300,000
Management complications result in 6000 US deaths/year
Cholelithiasis
Incidence
increases with age
However children have an
Incidence
of Gallstones of 1.9%
Females are more often affected after
Puberty
Prior to
Puberty
, males and females have equal
Incidence
of
Gall Bladder
disorders
Definitions
Biliary Colic
Transient cystic duct obstruction
Cholelithiasis
Presence or formation of Gallstones
Acute Cholecystitis
Persistent obstruction of the cystic duct with constant pain (contrast with
Biliary Colic
)
Results in gallbladder wall thickening, serious infection or perforation
Choledocholithiasis
Calculi in the common bile duct
Acute Gallstone Cholangitis
(
Ascending Cholangitis
)
Acute biliary tract infection caused by
Bacteria
ascending from the
Small Intestine
Risks Factors
Cholesterol
Gallstones
Classic 5 F's
Female
Forty (age over 40 years)
Fair skinned (Scandinavian)
Family History
(first degree relative)
Specific races (e.g. Chilean Indians, Mexican Americans, Pima Indians)
Fat (
Obesity
with BMI >30)
This applies to children as well
Dietary factors
High calorie diet
Excessive intake of refined
Carbohydrate
s
Low fiber intake
Prolonged
Fastin
g
Rapid weight loss (e.g. post-
Bariatric Surgery
)
Total Parenteral Nutrition
(TPN) Cholestasis
Common cause in children with serious comorbidity
Associated Conditions
Alcohol
ic
Cirrhosis
Bariatric Surgery
History of ileal disease, resection or bypass
Diabetes Mellitus
,
Metabolic Syndrome
or Hyperinsulinism
Hyperlipidemia
(dyslipidemia)
Obesity
Pregnancy
Celiac Disease
Congenital Causes (esp. Children)
Sickle Cell Anemia
(most common cause in children)
Hereditary Spherocytosis
Cystic Fibrosis
Obesity
Medications
Estrogen Replacement
(e.g. Premarin)
Oral Contraceptive
s
Ceftriaxone
Pathophysiology
Gall Stones
Solid calculi form when there is impaired gallbladder motility
Composition
Cholesterol
stones (80% of Gallstones in U.S.)
Cholesterol
and bile supersaturation which precipitates into
Cholesterol
monohydrate crystals
Black pigment stones (20% of Gallstones in U.S.)
Polymerized calcium
Bilirubin
ate
Progression to symptoms
Gallbladder distention (hydrops)
Serosal edema
Infection secondary to obstructed cystic duct
Differential Diagnosis
Typical right upper quadrant and
Epigastric Pain
presentations
Hepatitis
Hepatic Abscess
Pancreatitis
Gastritis
Peptic Ulcer Disease
(perforated or penetrating)
Gastroesophageal Reflux
disease
Atypical presentations in the abdominal RUQ or epigastric region
Fitz Hugh-Curtis Syndrome
Gonorrhea
or
Chlamydia
perihepatitis
Pelvic Inflammatory Disease
Appendicitis
Pyelonephritis
Chest
conditions with radiation into abdominal RUQ or epigastric region
Right lower lobe
Pneumonia
Myocardial Ischemia
or
Myocardial Infarction
Types
Gallbladder Disease
Biliary Colic
Acalculous Cholecystitis
(
Biliary Dyskinesia
)
Acute Cholecystitis
Ascending Cholangitis
Findings
Symptoms and Signs
See
Biliary Colic
Imaging
Gallbladder Ultrasound
HIDA Scan
(
Hepatobiliary Iminodiacetic Acid
Scan)
Magnetic Resonance Cholangiopancreatography
(
MRCP
)
Management
Approach
Watchful waiting (expectant management, no intervention) Indications
Asymptomatic Gallstones (incidentally identified on imaging)
Pregnancy and symptomatic Gallstones
Watchful waiting or
Cholecystectomy
indications
Symptomatic Gallstones without complications (e.g.
Biliary Colic
)
Symptoms resolve in 50% of patients without surgery
Verhus (2002) Scand J Gastroenterol 37:834-9 [PubMed]
Cholecystectomy
indications
Recurrent bililary colic
Acute Cholecystitis
Cholecystectomy
within 72 hours of onset
Gallstone
Pancreatitis
Cholecystectomy
prior to
Pancreatitis
hospitalization discharge
Gallbladder Calcification (porcelain gallbladder)
Risk of gallbladder cancer
Hemolytic Anemia
Chronic
Hemolysis
is high risk for formation of black pigmented stones (calcium
Bilirubin
ate Gallstones)
Large Gallstones (>3 cm)
High risk of gallbladder cancer
Pending
Bariatric Surgery
for morbid
Obesity
High risk of symptomatic gallbladder disease related to rapid weight loss
Native american ethnicity
Higher risk of gallbladder cancer
Pending transplant (with
Immunosuppression
)
Chronic
Immunosuppression
risks blunted gallbladder symptoms and increased risk of
Ascending Cholangitis
Gallbladder dysmotility and small Gallstones
Increased risk of gallstone
Pancreatitis
Pregnancy and recurrent or intractable biliary pain (or associated complications)
Symptomatic management is preferred
However
Laparoscopic Cholecystectomy
is indicated if uncontrolled, persistent symptoms
Child-Pugh Class
A or B
Cirrhosis
Laparoscopic Cholecystectomy
is indicated for symptomatic Gallstones (despite the increased complication risk)
ERCP
and
Cholecystectomy
indications
Choledocholithiasis
Percutaneous cholecystostomy drainage indications (with delayed
Cholecystectomy
)
Older or critically ill patients with gallbladder empyema (and associated
Sepsis
)
Complications
Acute Cholecystitis
Choledocholithiasis
Acute Gallstone Cholangitis
(
Ascending Cholangitis
)
Gallstone
Pancreatitis
Complications
Post-
Cholecystectomy
See
Cholecystectomy
Course
Asymptomatic Gallstones
Symptoms developing in Cholelithiasis: 2% per year (average)
Symptoms within 5 years of diagnosis: 10%
Symptoms within 10 years of diagnosis: 20%
References
Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
Portincasa (2006) Lancet 368(9531):230-9 [PubMed]
Type your search phrase here