Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. Biliary sludge is often a precursor of gallstones. It consists of Ca bilirubinate (a polymer of bilirubin), cholesterol microcrystals, and mucin. Sludge can evolve into gallstones or migrate into the biliary tract, obstructing the ducts and leading to biliary colic, cholangitis, or pancreatitis. Risk factors for gallstones are the 5 F’s: female, fat, fertile, forty and flatulent.
Cholesterol stones account for > 85% of gallstones in the Western world. For cholesterol gallstones to form, the following is required:
Symptoms: About 80% of people with gallstones are asymptomatic. The remainder have symptoms ranging from biliary-type pain (biliary colic) to cholecystitis to life-threatening cholangitis. Biliary colic is the most common symptom.
Biliary colic characteristically begins in the right upper quadrant but may occur elsewhere in the abdomen. The pain may radiate into the back or down the arm. Episodes begin suddenly, become intense within 15 min to 1 h, remain at a steady intensity (not colicky) for up to 12 h (usually < 6 h), and then gradually disappear over 30 to 90 min, leaving a dull ache. The pain is usually severe enough to send patients to the emergency department for relief. Nausea and some vomiting are common, but fever and chills do not occur unless cholecystitis has developed. This biliary-type pain can follow a heavy meal.
Diagnosis: Right Upper Quadrant Ultrasound
Gallstones are suspected in patients with biliary colic. Abdominal ultrasonography is the method of choice for detecting gallbladder stones; sensitivity and specificity are 95%.
Complications include cholecystitis, choledocholithiasis, cholangitis and gallstone pancreatitis.
Treatment:
Laparoscopic cholecystectomy for symptomatic stones
Expectant management for asymptomatic stones; sometimes stone dissolution
Surgery: Surgery can be done with an open or laparoscopic technique.
Open cholecystectomy, which involves a large abdominal incision and direct exploration, is safe and effective. Its overall mortality rate is about 0.1% when done electively during a period free of complications.
Laparoscopic cholecystectomy is the treatment of choice. Using video endoscopy and instrumentation through small abdominal incisions, the procedure is less invasive than open cholecystectomy. The result is a much shorter convalescence, decreased postoperative discomfort, improved cosmetic results, yet no increase in morbidity or mortality.
Stone dissolution: For patients who decline surgery or who are at high surgical risk (eg, because of concomitant medical disorders or advanced age), gallbladder stones can sometimes be dissolved by ingesting bile acids orally for many months.
Ursodeoxycholic acid 8 to 10 mg/kg/day po dissolves 80% of tiny stones < 0.5 cm in diameter within 6 mo. Ursodeoxycholic acid can also help prevent stone formation in morbidly obese patients who are losing weight rapidly after bariatric surgery or while on a very low calorie diet.
CLINICAL VIGNETTES
A patient experiences intermittent, severe pain in the right upper quadrant of the abdomen, especially after fatty meals. Ultrasound demonstrates multiple small opacities in the gall bladder that change with the patient’s position. Which of the following is a risk factor for this patient’s disorder?
A. 20 years of age
B. Male sex
C. Native American origin
D. Nulliparity
E. Thin build
The correct answer is C. The patient has gallstones (cholelithiasis). A useful mnemonic to remember the risk factors for gallstones is the 5 F’s: female, fat, fertile, forty, and flatulent. Gallstones are usually composed predominantly of cholesterol with lesser amounts of other components such as calcium salts, bile acids, and bile pigments. Exceptions to this rule are nearly pure cholesterol stones and pigment (calcium bilirubinate) stones. The incidence of mixed stones and cholesterol stones is also increased in association with Crohn’s disease, cystic fibrosis, clofibrate therapy, estrogen therapy, rapid weight loss, and Native American origin. Risk factors for pigment stones include chronic hemolysis, alcoholic cirrhosis, and biliary infection.
The typical age for gallstones is Forty years or older, not 20 years (choice A). Female, not male (choice B) sex predisposes the individual for gallstones. Many patients with gallstones are multiparous (Fertile), not nulliparous (choice D). Gallstones are associated with obesity (Fat), not a thin build (choice E).
A 46-year-old obese woman presents with a 6-hour history of moderate pain in the RUQ that began after eating dinner and radiates through to her back. This pain gradually increased before becoming constant over the last few hours. She has had previous episodes of similar pain for which she has not sought medical advice. Her vital signs are normal. The pertinent findings on physical exam are tenderness to palpation in the right upper quadrant with no guarding or rebound tenderness.
Cholelithiasis
Cholecystitis
Choledocholithiasis
Acute Pancreatitis
Answer is A.
B. Cholecystitis: biliary pain is accompanied by features of inflammation, with fever, marked RUQ tenderness (Murphy sign), and leukocytosis. Some patients progress to sepsis. Occasionally, stones can perforate the gallbladder leading to intestinal obstruction (gallstone ileus).
C. Choledocholithiasis: when stones obstruct the bile ducts, biliary-type pain is accompanied by cholestasis which manifests as jaundice. More sinister is acute cholangitis, characterized by the Charcot triad of biliary pain, jaundice, and fever. Sepsis often represents a medical emergency.
D. Acute pancreatitis: epigastric pain radiating to the back results from bile duct stones obstructing the pancreatic ducts.