Introduction

-Gallstones are hardened deposits of cholesterol, calcium salts, proteins and mucin.

-They are broadly classified into cholesterol stones and pigment stones.  

–Pigment stones can be further classified as either black or brown.

-In Western countries, about 80% of gallstones are cholesterol stones.

-Parasitic infection with Ascaris lumbricoides or Clonorchis sinensis can cause brown stones.

-Typical patient with gallstones is female, who is on a high dietary fat intake, has had prior pregnancies.

-Risk factors for gallstones: Female sex, increasing age, pregnancy, diabetes mellitus, rapid weight loss, obesity, certain medications, Native American (Pima Indians) and Hispanic heritage

–Rapid weight loss following bariatric surgery or lifestyle changes can  precipitate gallstone formation

Signs & Symptoms:

-The majority of patients with gallstones are asymptomatic.

-Symptomatic patients present with biliary colic (an intense discomfort in the right upper quadrant which may radiate to the right shoulder blade), nausea, vomiting,  abdominal bloating, early satiety, belching, and diaphoresis

–The biliary colic develops when a stone obstructs the cystic duct, resulting in a progressive increase of tension in the gallbladder wall as it contracts in response to a meal.

– Th pain is severe and comes on abruptly, typically during the night or after a fatty meal.

Diagnosis: Transabdominal ultrasound (the most sensitive imaging modality to detect gall stones)

Labs:  WBC, LFTs are usually normal; Amylase and lipase levels may be increased if stone obstruction occurs at the ampulla hepatopancreatica.

X rays: Most cholesterol stones (>90%) are radiolucent

Treatment:

Asymptomatic Incidental gallstones: Expectant management

Symptomatic:

-Pain control with NSAIDS

-Nonsurgical: Oral bile acid dissolution therapy (Ursodeoxycholic acid); Abdominal ultrasound every 6 to 12 months to assess the response, Percutaneous stone extraction, lithotripsy

-Surgical: Cholecystectomy

Prognosis:

-The prognosis is excellent after cholecystectomy

–Cholecystectomy & Cancer: Cholecystectomy may increase the risk of esophageal, proximal small intestinal, and colonic adenocarcinomas because of increased duodenogastric reflux and changes in intestinal exposure to bile.

-Complications of gallsones: Acute cholecystitis, obstructive choledocholithiasis, gallstone pancreatitis, gallstone ileus

-Gallstones in pregnancy: Pregnancy is a risk factor for the development of cholesterol gallstones and biliary sludge. Both progesterone and estrogen increase bile lithogenicity; progesterone decreases gallbladder contractility.

1. What is the chief symptom associate with cholelithiasis? Biliary colic
2. What is the most sensitive imaging test to detect gallstones: Ultrasonography