Cholelithiasis

PATHOGENESIS:
Lithogenic bile
  • Normal ratio of bile acids : cholesterol = 25:1
  • critical ratio < 13 :
  • 1Increased cholesterol
  • Decreased bile salts
  • Decreased entero hepatic circulation
Stasis
  • Prolonged TPN
  • Fasting
  • Pregnancy
  • Drugs- octreotide, estrogen therap
  • yBurns
  • Vagotomy
PREDISPOSING FACTOR:
Cholesterol stones
  • Old age
  • Female sex, pregnancy
  • Obesity,
  • Hyperlipidemia
  • Rapid weight reduction
  • Drugs: OCPs, Estrogen, Clofibrate, Cholestyramine
  • Gall bladder hypomotility (TPN, fasting, pregnancy, octreotide
  • Diabetes mellitus
  • Spinal cord injury
  • High calorie diet, High fat diet
  • Chronic hemolytic disease (sickle cell anemia, spherocytosis)
  • Ileal resection or disease
  • Cystic fibrosis
  • Chronic liver disease
  • Crohn's disease
  • Prolonged parenteral nutrition
  • Prematurity with complicated medical or surgical course
  • Prolonged fasting or rapid weight reduction
  • Treatment of childhood cancer
  • Abdominal surgery
  • Pregnancy
Pigment stones


Black pigment Brown pigment
  • Insoluble bilirubin with calcium phosphate and calcium bicarbonate
  • Usually in sterile GB
  • Small, multiple and hard
  • Haemolytic states – hereditary spherocytosis, sickle cell disease, thalassemia, malaria
  • Mechanical heart valves
  • Calcium bilirubinate, calcium palmitate, calcium stearate and cholesterol
  • Formed in biliary tree
  • Commonly due to infection (MC-E.coli)
  • Presence of stents
  • Parasites (Ascaris lumbricoides and Clonorchis sinensis)
  • Cirrhosis patients have a higher incidence of pigment stones
CLINICAL FEATURES:
  • 5 Fs: Flat, Fertile, Flatulent, Female, Forty
  • Commonest type of gall stone is mixed
  • Childhood cholelithiasis is seen in Neimann Pick's disease
  • Illeo cecal junction is the most common site of intestinal obstruction caused by a gall stone
  • Biliary colic with periodicity, severe within hours after meal (commonest presentation)
  • The Gall stone pain is referred to the shoulder through C3-05
  • Dyspepsia is a common symptom
  • Cholesterol stones are mostly radio-lucent
  • Gall stones contains Cholestrol, Phosphate, Carbonate
  • Pigment stones are mostly radio opaque
  • No resolution of symptoms, fever and leucocytosis Acute cholecystitis
  • The commonest site of obstruction in Gall stone ileus is Distal ileum
  • Centre of the stone may contain radiolucent gas which is either triradiate (Mercedes Benz sign) or biradiate (Seagull sign)
  • GB may be filled with toothpaste like material(calcium carbonate + phosphate) – limey gall bladder
  • Bouveret's syndrome or gallstone ileus- a large stone may erode directly into an adjacent loop of small bowel causing intestinal obstruction
COMPLICATION:
In the gallbladder:
  1. Silent stones
  2. Chronic cholecystitis
  3. Acute cholecystitis
  4. Gangrene
  5. Perforation
  6. Empyema
  7. Mucocele
  8. Carcinoma
  9. Somatostatinoma(most common)
  • In the bile ducts:
  1. Obstructive jaundice
  2. Cholangitis
  3. Acute pancreatitis
  • In the intestine: Acute intestinal obstruction (gallstone ileus)A gall stone gets impacted most commonly in Ampulla of vater of common bile duct
Management
  • Investigation of choice – USG
  • Best investigation for diagnosis of ampullary gall stone with obstructive jaundice is ERCP
  • 10% Percent of gall stones are radio opaque
  • Prophylactic cholecystectomy can be considered in
  1. Diabetic patients
  2. Congenital haemolytic anemia
  3. Patients undergoing Bariatric surgery
  • The treatment priority should focus on relief of obstruction and not on gall bladder and its fistulous communication
  • Multiple Gall stones & 8 mm dilation with 4 stones in CBD, best treatment modalities are Cholecystectomy with choledocholithotomy at same setting
  • Elective open cholecystectomy for cholelithiasis is the surgical procedures is considered to have a clean-contaminated wound
  • Cholecystectomy if it is asymptomatic but develops biliary colic
  • Symptomatic gallstones are the main indication for cholecystectomy.
  • Absolute contraindications for the procedure are uncontrolled coagulopathy and end-stage liver disease.
  • Medical therapy for gall stone dissolution utilizes two bile acids
  1. Ursodeoxycholic acid (UDCA)
  2. Chenodeoxycholic acid (CDCA)
  • For patients with serious comorbid conditions not responding to conservative treatment – percutaneous cholecystostomy is performed under USG control, which will rapidly relieve the symptoms. A subsequent cholecystectomy is usually required
  • Recurrent attacks of cholelithiasis, U/S examination shows a dilated CBD of 1 cm is best treated with ERCP
  • Surgery: lap cholecystectomy or open cholecystectomy through right subcostal Kocher's incision
  • Open cholecystectomy for cholelithiasis is considered a clean contaminated wound
  • Indication for medical treatment in gall stone is stone
  1. size less than 15mm,
  2. Radioluscent stones,
  3. Functioning gall bladder,
  4. Non acute symptoms
  • Contraindications for medical management are:
  1. Radio-opaque concretions
  2. Gallstones >20mm in diameter
  3. Non opacified gall bladder
  4. Acute &/or chronic cholecystitis
  5. Complications of gallstones
  6. Poor patient compliance
Exam Question
  • Solitary gall stone 1.5 cm in size without symptoms can be treated with Cholecystectomy if it develops biliary colic
  • Mercedes Benz sign is seen in Gall stone
  • Gall stones in children is caused by Chronic hemolytic disease (sickle cell anemia, spherocytosis),Obesity & Prematurity with complicated medical or surgical course Open cholecystectomy for cholelithiasis is considered a clean contaminated wound
  • History of epigastric pain radiating to back along with an enlarged (edematous) pancreas revealing cholelithiasis on ultrasonography suggests a diagnosis of Acute Pancreatitis. Illeo cecal junction is the most common site of intestinal obstruction caused by a gall stone
  • Radio-opaque stones is a contraindication for medical management of Gall stones
  • Cholelithiasis is particularly seen in association with Somatostatinoma malignancy 
  • Gall stones in hemolytic anaemia are Pigmented
  • Childhood cholelithiasis is seen in Neimann Pick's disease
  • Investigation of choice for gall stone is USG
  • The commonest site of obstruction in Gall stone ileus is Distal ileum
  • The treatment of gall stone ileus is Removal of obstruction
  • Gall stones is More common in female
  • Coronary artery disease with asymptomatic gall bladder stones should not be treated with surgery
  • Indication for medical treatment in gall stone is stone size less than15mm
  • Ursodeoxycholic acid is Gall stone dissolving drug
  • Multiple Gall stones & 8 mm dilation with 4 stones in CBD, best treatment modalities are Cholecystectomy with choledocholithotomy at same setting
  • Recurrent attacks of cholelithiasis, U/S examination shows a dilated CBD of 1 cm is best treated with ERCP
  • The Gall stone pain is referred to the shoulder through C3-05
  • Commonest type of gall stone is mixed
  • 10% Percent of gall stones are radio opaque
  • A gall stone gets impacted most commonly in Ampulla of vater of common bile duct
  • Gall stones contains Cholestrol, Phosphate, Carbonate
  • Cholesterol gall stones are due to Increased cholesterol,Decreased bile salts,Decreased entero hepatic circulation
  • Elective open cholecystectomy for cholelithiasis is the surgical procedures is considered to have a clean-contaminated wound
  • Best investigation for diagnosis of ampullary gall stone with obstructive jaundice is ERCP
Don't Forget to Solve all the previous Year Question asked on Cholelithiasis