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Gallstone disease

Types of gall stone and aetiology


Normal bile consists of 70% bile salts (mainly cholic and chenodeoxycholic acids), 22% phospholipids (lecithin), 4% cholesterol, 3% proteins, and 0.3% bilirubin. holesterol or cholesterol predominant (mixed) stones account for !0% of all "all stones in the #nited $in"dom and form %hen there is supersaturation of bile %ith cholesterol. &ormation of stones is further aided by decreased "allbladder motility. 'lac( pi"ment stones consist of 70% calcium bilirubinate and are more common in patients %ith haemolytic diseases (sic(le cell anaemia, hereditary spherocytosis, thalassaemia) and cirrhosis. 'ro%n pi"ment stones are uncommon in 'ritain (accountin" for )*% of stones) and are formed %ithin the intraheptic and extrahepatic bile ducts as %ell as the "all bladder. +hey form as a result of stasis and infection %ithin the biliary system, usually in the presence of Escherichia coli and Klebsiella spp, %hich produce , "lucuronidase that con-erts soluble con.u"ated bilirubin bac( to the insoluble uncon.u"ated state leadin" to the formation of soft, earthy, bro%n stones. Ascaris lumbricoides and Opisthorchis senensis ha-e both been implicated in the formation of these stones, %hich are common in /outh 0ast 1sia. 2o to3

Clinical presentations
Biliary colic or chronic cholecystitis
+he commonest presentation of "allstone disease is biliary pain. +he pain starts suddenly in the epi"astrium or ri"ht upper 4uadrant and may radiate round to the bac( in the interscapular re"ion. ontrary to its name, the pain often does not fluctuate but persists from 5* minutes up to 24 hours, subsidin" spontaneously or %ith opioid anal"esics. Nausea or -omitin" often accompanies the pain, %hich is -isceral in ori"in and occurs as a result of distension of the "allbladder due to an obstruction or to the passa"e of a stone throu"h the cystic duct. 2o to3

Risk factors associated with formation of cholesterol gall stones


61"e 740 years 6&emale sex (t%ice ris( in men) 62enetic or ethnic -ariation 69i"h fat, lo% fibre diet 6 'ile salt loss (ileal disease or resection) 6 8iabetes mellitus 6 ystic fibrosis 6 1ntihyperlipidaemic dru"s

6:besity 6;re"nancy (ris( increases %ith number of pre"nancies) 69yperlipidaemia 2o to3

(clofibrate) 6 2allbladder dysmotility 6 ;rolon"ed fastin" 6 +otal parenteral nutrition

Differential diagnosis of common causes of severe acute epigastric pain


'iliary colic ;eptic ulcer disease :esopha"eal spasm <yocardial infarction 1cute pancreatitis

<ost episodes can be mana"ed at home %ith anal"esics and antiemetics. ;ain continuin" for o-er 24 hours or accompanied by fe-er su""ests acute cholecystitis and usually necessitates hospital admission. #ltrasono"raphy is the definiti-e in-esti"ation for "all stones. =t has a >*% sensiti-ity and specificity for stones o-er 4 mm in diameter. Non?specific abdominal pain, early satiety, fat intolerance, nausea, and bo%el symptoms occur %ith comparable fre4uency in patients %ith and %ithout "all stones, and these symptoms respond poorly to inappropriate cholecystectomy. =n many of these patients symptoms are due to upper "astrointestinal tract problems or irritable bo%el syndrome.

Acute cholecystitis
@hen obstruction of the cystic duct persists, an acute inflammatory response may de-elop %ith a leucocytosis and mild fe-er. =rritation of the ad.acent parietal peritoneum causes localised tenderness in the ri"ht upper 4uadrant. 1s %ell as "all stones, ultrasono"raphy may sho% a tender, thic( %alled, oedematous "all bladder %ith an abnormal amount of ad.acent fluid. Ai-er enByme acti-ities are often mildly abnormal. =nitial mana"ement is %ith non?steroidal anti?inflammatory dru"s (intramuscular or per rectum) or opioid anal"esic. 1lthou"h acute cholecystitis is initially a chemical inflammation, secondary bacterial infection is common, and patients should be "i-en a broad spectrum parenteral antibiotic (such as a second "eneration cephalosporin). ;ro"ress is monitored by resolution of tachycardia, fe-er, and tenderness. =deally cholecystectomy should be performed durin" the same admission as delayed cholecystectomy

has a 5*% failure rate (empyema, "an"rene, or perforation) and a 5*% readmission rate %ith further pain.

Jaundice
Caundice occurs in patients %ith "all stones %hen a stone mi"rates from the "all bladder into the common bile duct or, less commonly, %hen fibrosis and impaction of a lar"e stone in 9artmannDs pouch compresses the common hepatic duct (<irriBiDs syndrome). Ai-er function tests sho% a cholestatic pattern (raised con.u"ated bilirubin concentration and al(aline phosphatase acti-ity %ith normal or mildly raised aspartate transaminase acti-ity) and ultrasono"raphy confirms dilatation of the common bile duct (77 mm diameter) usually %ithout distention of the "all bladder.

Acute cholangitis
@hen an obstructed common bile duct becomes contaminated %ith bacteria, usually from the duodenum, cholan"itis may de-elop. #r"ent treatment is re4uired %ith broad spectrum antibiotics to"ether %ith early decompression of the biliary system by endoscopic or radiolo"ical stentin" or sur"ical draina"e if stentin" is not a-ailable. 8elay may result in septicaemia or the de-elopment of li-er abscesses, %hich are associated %ith a hi"h mortality. 2o to3

Charcot's triad of symptoms in severe cholangitis


;ain in ri"ht upper 4uadrant Caundice 9i"h s%in"in" fe-er %ith ri"ors and chills

Acute pancreatitis
1cute pancreatitis de-elops in *% of all patients %ith "all stones and is more common in patients %ith multiple small stones, a %ide cystic duct, and a common channel bet%een the common bile duct and pancreatic duct. /mall stones passin" do%n the common bile duct and throu"h the papilla may temporarily obstruct the pancreatic duct or allo% reflux of duodenal fluid or bile into the pancreatic duct resultin" in acute pancreatitis. ;atients should be "i-en intra-enous fluids and anal"esia and be monitored carefully for the de-elopment of or"an failure (see later article on acute pancreatitis).

Gallstone ileus
1cute cholecystitis may cause the "all bladder to adhere to the ad.acent .e.unum or duodenum. /ubse4uent inflammation may result in a fistula bet%een these structures and the passa"e of a "all stone into the bo%el. Aar"e stones may become impacted and obstruct the small bo%el.

1bdominal radio"raphy sho%s obstruction of the small bo%el and air in the biliary tree. +reatment is by laparotomy and Emil(in"F the obstructin" stone into the colon or by enterotomy and extraction. 2o to3

atural course of gallstone disease


+%o thirds of "all stones are asymptomatic, and the yearly ris( of de-elopin" biliary pain is 5? 4%. ;atients %ith asymptomatic "all stones seldom de-elop complications. ;rophylactic cholecystectomy is therefore not recommended %hen stones are disco-ered incidentally by radio"raphy or ultrasono"raphy durin" the in-esti"ation of other symptoms. 1lthou"h "all stones are associated %ith cancer of the "all bladder, the ris( of de-elopin" cancer in patients %ith asymptomatic "all stones is )0.05%Gless than the mortality associated %ith cholecystectomy. ;atients %ith symptomatic "all stones ha-e an annual rate of de-elopin" complications of 5?2% and a *0% chance of a further episode of biliary colic. +hey should be offered treatment. 2o to3

!anagement of gallstone disease


Cholecystectomy
holecystectomy is the optimal mana"ement as it remo-es both the "all stones and the "all bladder, pre-entin" recurrent disease. +he only common conse4uence of remo-in" the "all bladder is an increase in stool fre4uency, %hich is clinically important in less than *% of patients and responds %ell to standard antidiarrhoeal dru"s %hen necessary. 2o to3

Causes of pain after cholecystectomy


Hetained or recurrent stone (dilatation of common bile duct seen in only 30% of patients) =atro"enic biliary lea( or stricture of common bile duct ;apillary stenosis or dysfunctional sphincter of :ddi =ncorrect preoperati-e dia"nosisGfor example, irritable bo%el syndrome, peptic ulcer, "astro?oesopha"eal reflux

Aaparoscopic cholecystectomy has been adopted rapidly since its introduction in 5>!7, and !0? >0% of cholecystectomies in the #nited $in"dom are no% carried out in this %ay. +he only specific contraindications to laparoscopic cholecystectomy are coa"ulopathy and the later sta"es

of pre"nancy. 1cute cholecystitis and pre-ious "astroduodenal sur"ery are no lon"er contraindications but are associated %ith a hi"her rate of con-ersion to open cholecystectomy. Aaparoscopic cholecystectomy has a lo%er mortality than the standard open procedure (0.5% v 0.*% for the open procedure). +his is mainly because of a lo%er incidence of postoperati-e cardiac and respiratory complications. +he smaller incisions cause less pain, %hich reduces the re4uirement for opioid anal"esics. ;atients usually stay in hospital for only one ni"ht in most centres, and the procedure can be done as a day case in selected patients. <ost patients are able to return to sedentary %or( after 7?50 days. +his decrease in o-erall morbidity and earlier reco-ery has led to a 2*% increase in the rate of cholecystectomy in some countries. +he main disad-anta"e of the laparoscopic techni4ue has been a hi"her incidence of in.ury to the common hepatic or bile ducts (0.2?0.4% v 0.5% for open cholecystectomy). 9i"her rates of in.ury are associated %ith inexperienced sur"eons (the Elearnin" cur-eF phenomenon) and acute cholecystitis. &urthermore, in.uries to the common bile duct tend to be more extensi-e %ith laparoscopic sur"ery. 9o%e-er, there is some e-idence su""estin" that the rates of in.ury are no% fallin".

Alternative treatments
/e-eral non?sur"ical techni4ues ha-e been used to treat "all stones includin" oral dissolution therapy (chenodeoxycholic and ursodeoxycholic acid), contact dissolution (direct instillation of methyltetrabutyl ether or mono?octanoin), and stone shatterin" %ith extracorporeal shoc(%a-e lithotripsy. 2o to3

Criteria for non"surgical treatment of gall stones


holesterol stones )20 mm in diameter &e%er than 4 stones &unctionin" "all bladder ;atent cystic duct <ild symptoms

Aess than 50% of "all stones are suitable for non?sur"ical treatment, and success rates -ary %idely. /tones are cleared in around half of appropriately selected patients. =n addition, patients re4uire expensi-e, lifelon" treatment to counteract bile acid in order to pre-ent stones from reformin". +hese treatments should be used only in patients %ho refuse sur"ery. 2o to3

!anaging common #ile duct stones

1round 50% of patients %ith stones in the "allbladder ha-e stones in the common bile duct. ;atients may present %ith .aundice or acute pancreatitisI the results of li-er function tests are characteristic of cholestasis and a dilated common bile duct is -isible on ultrasono"raphy. +he optimal treatment is to remo-e the stones in both the common bile duct and the "all bladder. +his can be performed in t%o sta"es by endocsopic retro"rade cholan"iopancreato"raphy follo%ed by laparoscopic cholecystectomy or as a sin"le sta"e cholecystectomy %ith exploration of the common bile duct by laparoscopic or open sur"ery. +he morbidity and mortality (2%) of open sur"ery is hi"her than for the laparoscopic option. +%o recent randomised controlled trials ha-e sho%n laparoscopic exploration of the bile duct to be as effecti-e as endoscopic retro"rade cholan"iopancreato"raphy in remo-in" stones from the common bile duct. Aaparoscopic exploration has the ad-anta"e that the "all bladder is remo-ed in a sin"le sta"e procedure, thus reducin" hospital stay. =n practice, mana"ement often depends on local a-ailability and s(ills. +he 1' of diseases of the li-er, pancreas, and biliary system is edited by = C 'ec(in"ham, consultant hepatobiliary and laparoscopic sur"eon, department of sur"ery, JueenDs <edical entre, Nottin"ham =n elderly or frail patients endoscopic retro"rade cholan"iopancreato"raphy %ith di-ision of the sphincter of :ddi (sphincterotomy) and stone extraction alone (%ithout cholecsytectomy) may be appropriate as the ris( of de-elopin" further symptoms is only 50% in this population. @hen stones in the common bile duct are suspected in patients %ho ha-e had a cholecystectomy, endoscopic retro"rade cholan"iopancreato"raphy can be used to dia"nose and remo-e the stones. /tones are remo-ed %ith the aid of a dormia bas(et or balloon. &or multiple stones, a pi"tail stent can be inserted to drain the bileI this often allo%s subse4uent passa"e of the stones. Aar"e or hard stones can be crushed %ith a mechanical lithotripter. @hen cholan"iopancreato"raphy is not technically possible the stones ha-e to be remo-ed sur"ically. 2o to3

$ummary points

2all stones are the commonest cause for emer"ency hospital admission %ith abdominal pain Aaparoscopic cholecystectomy has become the treatment of choice for "allbladder stones His( of bile duct in.ury %ith laparoscopic cholecystectomy is around 0.2% 1symptomatic "all stones do not re4uire treatment holan"itis re4uires ur"ent treatment %ith antibiotics and biliary decompression by endoscopic retro"rade cholan"iopancreato"raphy

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