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Cholelithiasis And Choledocholithiasis

Surgery > Cholelithiasis And Choledocholithiasis

Key points

Cholelithiasis refers to the presence of gallstones in the gallbladder; choledocholithiasis refers to stones within the hepatic or common bile duct and may result in cholangitis, obstructive jaundice, and pancreatitis Increased frequency of cholelithiasis is seen in women over the age of 40 years and in those with prior or current pregnancy, estrogen use, diabetes, prolonged fasting (eg, in total parenteral nutrition [TPN] patients), rapid weight loss, hemolysis, or cirrhosis Abdominal ultrasound is the diagnostic tool of choice for cholelithiasis, as it is very sensitive and specific. Ultrasound is less sensitive for detecting choledocholithiasis (stones within the hepatic or common bile duct) Symptomatic gallstone disease is treated with cholecystectomy (preferred treatment). In cases where surgery is not desired cholecystostomy may be considered. Dissolution of gallstones with medication, lithotripsy, and other techniques are generally futile Symptomatic choledocholithiasis, especially if complicated by cholangitis, is treated by endoscopic retrograde cholangiopancreatography (ERCP) or if this fails, percutaneous transhepatic biliary drainage Complications of cholelithiasis include cholecystitis, choledocholithiasis, cholangitis, gallstone ileus, and, rarely, obstruction of the biliary tree by its external compression of a large gallstone within the gallbladder (Mirizzi syndrome) Urgent action is indicated in patients with acute cholecystitis, ascending cholangitis, or gallstone ileus

Background
Description

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Cholelithiasis refers to the presence of gallstones in the gallbladder Choledocholithiasis refers to stones within the hepatic or common bile duct and may result in cholangitis, obstructive jaundice, and pancreatitis. The majority (73%) of these pass into the duodenum without causing complications Pathophysiology of gallstone formation: The gallbladder concentrates and stores hepatic bile between meals and then releases the bile into the duodenum after food is ingested. This 'bolus' of bile aids in fat absorption Active sodium transport by the epithelium of the gallbladder causes concentration of the bile into a form that is up to 10 times more concentrated than when first excreted by the liver. This concentration process leads to changes in the solubility of the calcium and cholesterol components of the bile Decreased gallbladder motility with bile stasis contributes to stone formation. Conditions associated with gallstones and decreased gallbladder contraction include obesity, rapid weight loss, pregnancy, diabetes mellitus, TPN, and octreotide use

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Biliary tract infection may also contribute to stone formation Pigment stones can be black or brown in color. Black pigment stones are primarily composed of bilirubin calcium, which is cross-linked and oxidized to produce a black polymer. These stones are sterile and are found in patients with hemolysis, sickle cell disease, chronic TPN, and cirrhosis. Brown pigment stones, containing bacteria, complicate bacterial and helminthic common bile duct infections. Brown pigment stones are more common in the Asian population Complications from these stones include: Acute cholecystitis, gallbladder inflammation resulting from obstruction of the cystic duct. In 50% of patients there is no evidence of bacterial infection in the gallbladder bile Biliary colic, resulting from intermittent obstruction of the cystic or bile ducts Cholangitis, infection within the bile ducts, most commonly caused by obstruction. Symptoms frequently include right upper quadrant tenderness, fever, and jaundice (Charcot triad). Cholangitis is a serious medical problem and may require early duct decompression to prevent sepsis Gallstone ileus, which occurs when a large gallstone erodes through the wall of the gallbladder and into adjacent, adherent structures. Most commonly this is the duodenum, but it may also be the stomach or colon. A large gallstone may obstruct the small intestine, most commonly near the terminal ileum Cholesterol gallstones make up 75% of all gallstones; the remaining 25% are pigment stones. They are associated with obesity, diabetes, female gender, and childbearing; pigment stones are associated with hemolysis and cirrhosis of the liver The diagnostic tool of choice for cholelithiasis is the abdominal ultrasound, which has a sensitivity and specificity of 90%; the primary tool for diagnosis of choledocholithiasis is cholangiography (magnetic resonance cholangiopancreatography [MRCP] or ERCP) or endoscopic ultrasound. The false-negative rate for ultrasound is approximately 5% and may occur if the stones are small, there is little fluid around the stones (the stones are impacted), or if there is an ileus that creates gas patterns that impair the ultrasonic image The primary treatment of symptomatic cholelithiasis is laparoscopic cholecystectomy. Asymptomatic gallstones do not require surgical treatment or surveillance Most asymptomatic patients with cholelithiasis do not require treatment; however, once patients become symptomatic, laparoscopic cholecystectomy is indicated because the incidence of future recurrent pain and complications is high. Gallstones remain asymptomatic unless they cause obstruction of the cystic duct, biliary tree, pancreatic duct, or erode through the wall of the gallbladder causing a fistula to the intestine Approximately 10% of patients with asymptomatic stones will develop symptoms in the first 5 years after diagnosis and approximately 1% to 2% of patients per year will develop complications from the stones Biliary sludge is most often asymptomatic, but it can be associated with biliary colic (9.1% incidence), pancreatitis (3.1%), and acute acalculous cholecystitis (7.1%). The natural history of biliary sludge is not fully known

Epidemiology

Incidence and prevalence A recent study estimates an incidence rate of 1.39 per 100 persons per year

The third National Health and Nutrition Examination Survey (NHANES III) included an ultrasound examination of 14,000 individuals in 1993 to detect gallstone disease. This study revealed 16.6% of women and 7.7% of men had cholelithiasis Demographics Age:

After age 40 years the incidence of cholesterol gallstones increases with age; 20% of adults over age 40 years have gallstones, whereas 30% over age 70 years have gallstones The highest incidence occurs in the fifth and sixth decades of life. Cholesterol gallstones rarely occur in young adults and children under the age of 19 years Gender:

Cholelithiasis is more common in women than in men at all ages Race:

NHANES III showed some ethnic groups have higher prevalence, particularly in women. Mexican American women have the highest prevalence, followed by non-Hispanic white women, and then black women. Data from Asian populations suggest a lower prevalence. Mexican American and non-Hispanic white men have approximately the same prevalence; black men the lowest prevalence In addition, 75% of female Pima Indians aged older than 25 years have gallstones, as do 35% of the Mapuche Indians of Chile Genetics:

A family history of gallstones increases the risk for gallstones A mutation in the gene that encodes the hepatocanalicular phosphatidylcholine transporter in the ABCB4 gene appears to be a risk factor for symptomatic gallstone disease. This mutation results in enhanced cholesterol precipitation and gallstone formation as a result of low biliary levels of phosphatidylcholine Geography:

Cholelithiasis appears to be less common in Asian populations

Causes and risk factors


Cholesterol stones:

Age over 40 years Female gender Parity Estrogen therapy Rapid weight loss High-calorie diet Sedentary lifestyle Diabetes mellitus type 2 Dyslipidemia (increased LDL cholesterol level) TNP

Gastric bypass surgery Octreotide therapy Somatostatin secreting tumors Family history of cholelithiasis Pigment stones:

Cirrhosis Hemolysis Sickle cell disease Bacterial or helminthic biliary tract infections

Associated disorders

Patients with coronary artery disease also have a higher incidence of cholelithiasis than the general population. Although the mechanism may involve a common lipid abnormality, the actual reason for the association is not yet known Diabetes mellitus type 2 Hyperlipidemia Obesity Somatostatinoma, use of octreotide Hemolytic anemia (eg, sickle cell disease [pigment stone]) Cirrhosis

Screening
Not applicable.

Primary prevention
Summary approach
While some risk factors for cholelithiasis such as ethnicity and family history cannot be modified, others can (seePreventive measures below).

Population at risk
Characteristics of patients at risk include:

Age over 40 years Female gender Obesity or tendency to obesity Multiparous status Ongoing estrogen therapy Recent rapid weight loss

Preventive measures
Alcohol and drugs:

Alcohol use does not predispose to gallstones or to development of cholecystitis. Some medications are known to contribute to sludge formation (eg, estrogens). Avoiding these drugs in individuals who are at high risk for stone formation may be beneficial Diet:

Rapid weight loss can cause stone formation; maintenance on parenteral nutrition is associated with sludge and stone formation Medication history:

Octreotide, ceftriaxone, and estrogen therapy are associated with biliary sludge and stone formation Chemoprophylaxis:

Ursodiol may be used in some cases to prevent gallstone formation in patients who undergo rapid weight loss

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