Gallstones

AFIF BIN AIDIT082013100004

IMS BANGALORE

GALLSTONES

LEARNING OUTCOMES

Definition of gallstonesTypes of gallstonesFactors causing gallstonesFeatures of gallstonesInvestigations of gallstonesTreatment of gallstones

DEFINITION

Gallstone formation is most common disorder of biliary tree

Presence of stone in biliary tract is called gallstone or cholelithiasis

Commonly associated with 5 F’s : female, forty, fertile, fair and fat

Either cholesterol gallstones or pigment stones

PATHOPHYSIOLOGY

Cholesterol gallstones- Cholesterol is held in solution in bile - By its association with bile acids and

phospholipids in form of micelles and vesicles- Biliary lipoproteins have a role in solubilizing

cholesterol- In gallstone disease, liver produces bile- Contains an excess of cholesterol- Either a relative deficiency of bile salts or

relative excess of cholesterol

- Bile which is supersaturated with cholesterol is termed “lithogenic”

Factors leading to production of lithogenic bile

1) Defective bile salt synthesis

2) Excessive intestinal loss of bile salts

3) Over-sensitive bile salt feedback

4) Excessive cholesterol secretion

5) Abnormal gallbladder function

- Nucleation factors are factors initiating crystallization of cholesterol in lithogenic bile

- Patients with cholesterol gallstones have gallbladder bile which forms cholesterol crystals

- rapidly than equally saturated bile from patients who do not form gallstones

- Nucleation factors include mucus, calcium, fatty acids

- Anti-nucleation factors are apolipoproteins

RISK FACTORS FOR CHOLESTROL GALLSTONES

Increase cholesterol secretion

Impaired gallbladder emptying

Decrease bile salt secretion

1) Old age 1) Pregnancy 1) Pregnancy

2) Female 2) Gallbladder stasis

3) Pregnancy 3) Fasting

4) Obesity 4) Total parenteral nutrition

5) Rapid weight loss

5) Spinal cord injury

Pigment stones- Brown crumbly pigment stones usually

caused due to consequence of bacterial or parasitic infection in biliary tree

- Infection of biliary tree allows bacterial beta-glucuronidase to hydrolyse conjugated bilirubin to its free form

- Then precipitates as calcium bilirubinate

COMPOSITION OF PIGMENT STONES

Black BrownComposition 1)Polymerised

calcium2)Bilirubinates3)Mucin

glycoprotein4)Calcium

phosphate5)Calcium

carbonate6)Cholesterol

1)Calcium bilirubinate

2)Crystals3)Mucin

glycoprotein4)Cholesterol5)Calcium

palmitate/stearate

RISK FACTORS OF PIGMENT STONES

Black BrownRisk factors 1)Haemolysis

2)Age3)Hepatic

cirrhosis4)Ileal

resection

1)Infected bile2)stasis

CLINICAL FEATURES

Majority of gallstones are asymptomaticSymptomatic stones within the gallbladder

manifest as either biliary pain or cholecystitisIf gallstone becomes acutely impacted in cystic

duct, patient will experience painTypically the pain occurs suddenly and persists

up to 2 hoursUp to 6 hours, cholecystitis or pancreatitis may

be presentPain usually felt in epigastrium (70%) or right

upper quadrant (30%)

INVESTIGATIONS

Ultrasound (transabdominal ultrasound)MRCP CT scan

Medical dissolution of gallstone can be attempted

Long-term oral administration of bile acid ursodeoxycholic acid

Should consider in those with :1) Radiolucent gallstones2) Stones smaller than 15mm diameter3) Moderate obesity4) No or at most mild symptoms

MANAGEMENT

Gallbladder stones Bile duct stones1)Cholecystectomy :

Open or laparoscopic

2)Oral bile acids : chenodeoxycholic

1)Lithotripsy (endoscopic)

2)Endoscopic sphincterotomy and balloon trawl

3)Surgical bile duct

COMPLICATIONS OF GALLSTONES

1) Empyema of gallbladder2) Choledolithiasis3) Acute pancreatitis4) Cancer of gallbladder5) Mirizzi’s syndrome

REFERENCE

G.K Pal, Textbook of Medical Physiology 2th Edition

Davidson’s Principles And Practice Of Medicine 21st Edition