Gall Stone Diseases(Cholelithiasis)

د.مصطفى حجازى

Background

Cholelithiasis involves the presence of gallstones, which are concretions that form in the biliary tract, usually in the gallbladder.

Choledocholithiasis refers to the presence of 1 or more gallstones in the common bile duct (CBD).

Treatment of gallstones depends on the stage of disease.

Signs and symptoms

Gallstone disease may be thought of as having the following 4 stages:

Lithogenic state, in which conditions favor gallstone formation

Asymptomatic gallstones Symptomatic gallstones,

characterized by episodes of biliary colic

Complicated cholelithiasis

Signs and symptoms

Symptoms and complications result from effects occurring within the gallbladder or from stones that escape the gallbladder to lodge in the CBD.

Signs and symptoms

Characteristics of biliary colic include the following:

Sporadic and unpredictable episodes Pain that is localized to the

epigastrium or right upper quadrant, sometimes radiating to the right scapular tip

Signs and symptoms

Pain that begins postprandially, is often described as intense and dull, typically lasts 1-5 hours, increases steadily over 10-20 minutes, and then gradually wanes

Pain that is constant; not relieved by emesis, antacids, defecation, flatus, or positional changes; and sometimes accompanied by diaphoresis, nausea, and vomiting

Signs and symptoms

Nonspecific symptoms (eg, indigestion, dyspepsia, belching, or bloating)

Patients with the lithogenic state or asymptomatic gallstones have no abnormal findings on physical examination.

Signs and symptoms

Distinguishing uncomplicated biliary colic from acute cholecystitis or other complications is important.

Key findings that may be noted include the following:

Uncomplicated biliary colic – Pain that is poorly localized and visceral; an essentially benign abdominal examination without rebound or guarding; absence of fever

Signs and symptoms

Acute cholecystitis – Well-localized pain in the right upper quadrant, usually with rebound and guarding; positive Murphy sign (nonspecific); frequent presence of fever; absence of peritoneal signs; frequent presence of tachycardia and diaphoresis; in severe cases, absent or hypoactive bowel sounds

Signs and symptoms

The presence of fever, persistent tachycardia, hypotension, or jaundice necessitates a search for complications, which may include the following:

Cholecystitis Cholangitis Pancreatitis Other systemic cause

Diagnosis

Patients with uncomplicated cholelithiasis or simple biliary colic typically have normal laboratory test results; laboratory studies are generally not necessary unless complications are suspected.

Diagnosis

Blood tests, when indicated, may include the following:

Complete blood count (CBC) with differential

Liver function panel Amylase Lipase

Diagnosis

Imaging modalities that may be useful include the following:

Abdominal radiography (upright and supine) – Used primarily to exclude other causes of abdominal pain (eg, intestinal obstruction)

Diagnosis

Ultrasonography – The procedure of choice in suspected gallbladder or biliary disease

Diagnosis

Endoscopic ultrasonography (EUS) – An accurate and relatively noninvasive means of identifying stones in the distal CBD

Laparoscopic ultrasonography –Promising as a potential method for bile duct imaging during laparoscopic cholecystectomy

Diagnosis

Computed tomography (CT) – More expensive and less sensitive than ultrasonography for detecting gallbladder stones, but superior for demonstrating stones in the distal CBD

Diagnosis

Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) – Usually reserved for cases in which choledocholithiasis is suspected

Scintigraphy – Highly accurate for the diagnosis of cystic duct obstruction

Diagnosis

Endoscopic retrograde cholangiopancreatography (ERCP)

Percutaneous transhepatic cholangiography (PTC)

Management

The treatment of gallstones depends upon the stage of disease, as follows:

Lithogenic state – Interventions are currently limited to a few special circumstances

Asymptomatic gallstones – Expectant management

Management

Symptomatic gallstones – Usually, definitive surgical intervention (eg, cholecystectomy), though medical dissolution may be considered in some cases

Management

Medical treatments, used individually or in combination, include the following:

Oral bile salt therapy (ursodeoxycholic acid)

Contact dissolution Extracorporeal shockwave lithotripsy

Management

Cholecystectomy for asymptomatic gallstones may be indicated in the following patients:

Those with large (>2 cm) gallstones

Management

Those who have a nonfunctional or calcified (porcelain) gallbladder on imaging studies and who are at high risk of gallbladder carcinoma

Those with spinal cord injuries or sensory neuropathies affecting the abdomen

Those with sickle cell anemia in whom the distinction between painful crisis and cholecystitis may be difficult

Management

Patients with the following risk factors for complications of gallstones may be offered elective cholecystectomy, even if they have asymptomatic gallstones:

Cirrhosis Portal hypertension Children Transplant candidates Diabetes with minor symptoms

Management

Surgical interventions to be considered include the following:

Cholecystectomy (open or laparoscopic)

Cholecystostomy Endoscopic sphincterotomy

Medical Management

Oral bile acids have been used for years to dissolve common duct stones.

The success rates, however, are variable, ranging from 10% to 44%.

Medical Management• In one randomized, double-blind, placebo-controlled study, 28 patients with uncomplicated, non-obstructing common duct stones were treated with ursodeoxycholic acid (12 mg/kg/d for up to 2 years); the bile duct stones disappeared in 7 of 14 patients in the treatment group and 0 of 14 in the placebo group.

Medical Management Four patients (14%) required

operative intervention, including one from the treated and three from the placebo groups.

Rowachol (a terpene preparation) is known to further promote stone dissolution.

Medical Management Currently, optimal patient

selection,duration of treatment, and optimal dosing has not been determined with these medical treatments of choledocholithiasis.

Medical Management The area in which oral bile acid

therapy may play a role is the treatment of asymptomatic patients with small cholesterol duct stones discovered during laparoscopic cholecystectomy.

Medical Management The composition of bile ductal stones

may be inferred if cholesterol stones were present in the gallbladder, and small duct stones might dissolve relatively rapidly.

Medical Management Because duct exploration during

laparoscopic cholecystectomy might be demanding technically, especially with a small-diameter cystic and/or common bile duct, this dissolution therapy is a reasonable therapeutic alternative; however, this approach needs to be

evaluated in clinical trials.

Background

Cholelithiasis is the medical term for gallstone disease.

Gallstones are concretions that form in the biliary tract, usually in the gallbladder.

Background

Cholelithiasis A gallbladder filled with gallstones

(examined extracorporally after laparoscopic cholecystectomy .

Gallstones develop insidiously, and they may remain asymptomatic for decades.

Background

Migration of a a gallstone into the opening of the cystic duct may block the outflow of bile during gallbladder contraction.

Background

The resulting increase in gallbladder wall tension produces a characteristic type of pain (biliary colic).

Cystic duct obstruction, if it persists for more than a few hours, may lead to acute gallbladder inflammation (acute cholecystitis).

Background

Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct.

Usually, this occurs when a gallstone passes from the gallbladder into the common bile duct .

Background

Common bile duct stone (choledocholithiasis)

The sensitivity of transabdominal ultrasonography for choledocholithiasis is approximately 75% in the presence of dilated ducts and 50% for nondilated ducts.

Background

A gallstone in the common bile duct may impact distally in the ampulla of Vater, the point where the common bile duct and pancreatic duct join before opening into the duodenum.

Obstruction of bile flow by a stone at this critical point may lead to abdominal pain and jaundice.

Background

Stagnant bile above an obstructing bile duct stone often becomes infected, and bacteria can spread rapidly back up the ductal system into the liver to produce a life-threatening infection called ascending cholangitis.

Background

Obstruction of the pancreatic duct by a gallstone in the ampulla of Vater also can trigger activation of pancreatic digestive enzymes within the pancreas itself, leading to acute pancreatitis.[1, 2]

Background

Chronically, gallstones in the gallbladder may cause progressive fibrosis and loss of function of the gallbladder, a condition known as chronic cholecystitis.

Chronic cholecystitis predisposes to gallbladder cancer.

Background

Ultrasonography is the initial diagnostic procedure of choice in most cases of suspected gallbladder or biliary tract disease .

Background

The treatment of gallstones depends upon the stage of disease.

Asymptomatic gallstones may be managed expectantly.

Background

Once gallstones become symptomatic, definitive surgical intervention with excision of the gallbladder (cholecystectomy) is usually indicated.

Background

Cholecystectomy is among the most frequently performed abdominal surgical procedures .

Complications of gallstone disease may require specialized management to relieve obstruction and infection