Cholelithiasis

I. INTRODUCTION Cholelithiasis Gallstone disease, or cholelithiasis, is one of the most common surgical problems worldwide. They are a frequent cause of abdominal pain and dyspepsia. Causes Progress has been made in understanding the process of gallstone formation. Researchers believe that gallstones may be caused by a combination of factors, including inherited body chemistry, body weight, gallbladder motility (movement), and perhaps diet. Additionally, people with Erythropoietic Protoporphyria (EPP) are at increased risk to develop gallstones. Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high concentration of cholesterol, two other factors seem to be important in causing gallstones. The first is how often and how well the gallbladder contracts; incomplete and infrequent emptying of the gallbladder may cause the bile to become over concentrated and contribute to gallstone formation. The second factor is the presence of proteins in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones. In addition, increased levels of the hormone estrogen as a result of pregnancy, hormone therapy, or the use of combined (estrogen-containing) forms of hormonal contraception, may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation. No clear relationship has been proven between diet and gallstone formation. However, low-fiber, high-cholesterol diets, and diets high in starchy foods have been suggested as contributing to gallstone formation. Other nutritional factors that may increase risk of gallstones include rapid weight loss, constipation, eating fewer meals per day, eating less fish, and low intakes of the nutrients folate, magnesium, calcium, and vitamin C. On the other hand, wine, fish, and whole grain bread may decrease the risk of gallstones. Symptoms Gall stones usually remain asymptomatic initially. They start developing symptoms once the stones reach a certain size (>8mm). A main symptom of gallstones is commonly referred to as a gallstone "attack", in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately thirty minutes to several hours. A victim may also encounter pain in the back, ordinarily between the shoulder blades, or pain under the right shoulder. In some cases, the pain develops in the lower region of the stomach, nearer to the pelvis, but this is less common. Nausea and vomiting may occur. These attacks are intensely painful, similar to that of a kidney stone attack. One way to alleviate the abdominal pain is to drink a full glass of water at the start of an attack to

regulate the bile in the gallbladder, but this does not work in all cases. Another way is to take magnesium followed by a bitter liquid such as coffee or Swedish bitters an hour later. Bitter flavors stimulate bile flow. A study has found lower rates of gallstones in coffee drinkers. Often, these attacks occur after a particularly fatty meal and almost always happen at night. Other symptoms include abdominal bloating, intolerance of fatty foods, belching, gas, and indigestion. If the above symptoms coincide with chills, low-grade fever, yellowing of the skin or eyes, and/or clay-colored stool, a doctor should be consulted immediately. Some people who have gallstones are asymptomatic and do not feel any pain or discomfort. These gallstones are called "silent stones" and do not affect the gallbladder or other internal organs. They do not need treatment. Medical options Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid. Gallstones may recur however, once the drug is stopped. Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphinceterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP). A common misconception is that the use of ultrasound (Extracorporeal Shock Wave Lithotripsy) can be used to break up gallstones. Although this treatment is highly effective against kidney stones, it can only rarely be used to break up the softer and less brittle gallstones. Surgical options Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients must be indicated to surgery. The lack of a gall bladder does not seem to have any negative consequences in many people. However, there is a significant proportion of the population, between 5-40%, who develop a condition called postcholecystectomy syndrome. Symptoms include gastrointestinal distress and persistent pain in the upper right abdomen. There are two surgery options: open procedure and laparoscopic: see the cholecystectomy article for more details. •

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Open cholecystectomy procedure: This involves a large incision into the abdomen (laparotomy) below the right lower ribs. A week of hospitalization, normal diet a week after release and normal activity a month after release. Laparoscopic cholecystectomy: 3-4 small puncture holes for camera and instruments (available since the 1980s). Typically same-day release or one night hospital stay, followed by a week of home rest and pain medication. Can resume normal diet and light activity a week after release. (Decreased energy level and minor residual pain for a month or two.) Studies have shown that this procedure is as effective as the more invasive open cholecystectomy, provided the stones are accurately located by cholangiogram prior to the procedure so that they can all be removed. The procedure also has the benefit of reducing operative complications

such as bowel perforation and vascular injury.

Pathophysiology

Although gallstones can form anywhere in the biliary tree, the most common point of origin is within the gallbladder. There are 3 types of gallstones, pure cholesterol, pure pigment, and mixed. Under normal conditions, a delicate balance occurs among the levels of bile acids, cholesterol, and phospholipids. A disparity in this balance, especially with the supersaturation of cholesterol, predisposes patients to the formation of lithogenic bile and the subsequent development of cholesterol-type gallstones. Pigmented gallstones are composed of calcium bilirubinate and appear in 2 major forms, black and brown. Hemolysis and liver disease are associated with the black stones; the brown, earthy stones more frequently are formed outside the gallbladder and often are associated with bacterial infections of the biliary tract. Bile stasis predisposes to the formation of biliary sludge and eventual formation of

gallstones and commonly is seen in patients who are unable to take enteral nutrition. Infection of the biliary tree (especially with certain beta-glucuronidase-producing bacteria, such as Escherichia coli and parasites) is associated with an increased risk of ductal stone development. Intestinal resection is associated with an increased incidence of gallstones. Contrary to expectation, these are mainly of the pigment variety. Women are more likely to develop gallstones than men, with a ratio of 2:1. Classically, gallstones occur in obese, middle-aged women leading to the popular mnemonic, fat, fertile, forties. Oral contraceptive pills with high estrogen content increase the incidence of gallstones. The incidence increases with age

Clinical Features History: Gallstones usually remain asymptomatic throughout the patient’s life. The most common presenting symptom is intermittent pain below the right ribcage; pain might radiate to the back. • •

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Nausea, with or without vomiting, might be present. Certain foods, especially those with high fat content, can provoke symptoms. The patient might experience episodes of acute abdominal pain, called biliary colic. Physical: Physical examination frequently is normal. Discomfort might be elicited on deep palpation of the right upper quadrant of the abdomen. Murphy sign (pain on palpation of the right upper quadrant when the patient inhales) might indicate acute cholecystitis. Other signs of cholecystitis include fever and tachycardia. Physical exam might indicate complications of cholelithiasis. o Passage of gallstones from the gallbladder into the common bile duct can result in a complete or partial obstruction of the common bile duct. Frequently, this manifests as jaundice. In all races, jaundice is detected most reliably by examination of the sclera in natural for yellow discoloration. o Pancreatitis, another complication of gallstone disease, presents with more diffuse abdominal pain, including pain in the epigastrium and left upper quadrant of the abdomen. o Severe hemorrhagic pancreatitis occurs in 15% patients and carries a high mortality because of multisystem organ failure. In a few patients, the hemorrhagic pancreatic process and retroperitoneal bleeding induce discoloration around the umbilicus (Cullen sign) or the flank (Grey-Turner sign). o Charcot triad (right upper quadrant pain, fever, and jaundice) is associated with common bile duct obstruction and cholangitis. Additional symptoms, such as alterations in the mental status and hypotension, indicate Raynaud pentad, a harbinger of worsening, ascending cholangitis.

Mortality and morbidity are related directly to the complications of the disease and its

surgical treatment. Approximately 10% patients with gallstones have common bile duct stones as well. The natural history of common bile duct stones is not completely known. Gallstones can cause obstruction of the common bile duct, causing jaundice. Cholangitis, a potentially life-threatening infection, can follow biliary obstruction. Obstruction of the neck of the gallbladder causes bile stasis, which can lead to inflammation and edema of the gallbladder wall. Sequelae of this condition include acute cholecystitis secondary to compromised lymphatic, venous, and, ultimately, arterial supply to the gallbladder. The latter can lead to gangrene or abscess formation. Sources: http://en.wikipedia.org/wiki/Gallstone