NOV.

28, 2016

The gallbladder is a small pear-shaped organ which aids in the digestive process. Its function is
to store and concentrate bile - a digestive liquid continually secreted by the liver. The bile in turn
emulsifies fats and neutralizes acids in partly digested food. Despite its importance in the
digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the
gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of
the majority. The gallbladder tends to be taken for granted ignored of the proper care and
conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a
room for gallbladder complications to occur.
Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. More serious
complications include cholecystitis, biliary tract obstruction (from stones in the bile ducts or
choledocholithiasis), sometimes with infection (cholangitis) and gallstone pancreatitis.

Risk factors for gallstones include female sex, obesity, increased age, American Indian ethnicity,
a Western diet, and a family history. Most disorders of the biliary tract result from gallstones.
Those with asymptomatic gallstones become symptomatic at a rate of about 2%/yr. The symptom
that develops most commonly is biliary colic rather than a major biliary complication. Once
biliary symptoms begin, they are likely to recur; pain returns in 20 to 40% of patients/yr, while
about 1 to 2% of patients/yr develop complications such as cholecystitis, choledocholithiasis,
cholangitis, and gallstone pancreatitis.

. Every year, approximately 500,000 cholecystectomies are performed in the US.

Cholelithiasis affects approximately 10% of the adult population in the United States. It has been
well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults
over 40 years of age and 30% of those over age 70 have biliary calculi. The risk factors
predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy,
hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates
that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones
later developed complications or recurrent symptoms leading to cholecystectomy.

In Western countries, most cases of choledocholithiasis are secondary to the passage of

gallstones from the gallbladder into the common bile duct. Primary choledocholithiasis (ie,
formation of stones within the common bile duct) is less common. Primary choledocholithiasis
 typically occurs in the setting of bile stasis (eg, patients with cystic fibrosis), resulting in a higher
propensity for intraductal stone formation. Older adults with large bile ducts and periampullary
diverticular are at elevated risk for the formation of primary bile duct stones. Patients with
recurrent or persistent infection involving the biliary system are also at risk, a phenomenon seen
most commonly in populations from East Asia. (See "Recurrent pyogenic cholangitis".)

The causes of primary choledocholithiasis often affect the biliary tract diffusely, so patients may
have both extrahepatic and intrahepatic biliary stones. Intrahepatic stones may be complicated by
recurrent pyogenic cholangitis.

This topic will review the clinical manifestations and diagnosis of choledocholithiasis. The
treatment of choledocholithiasis, as well as the epidemiology and the general management of
patients with gallstones, are discussed separately:

About 10% of patients with symptomatic gallstones also have stones that pass into and
obstruct the common bile duct (choledocholithiasis).

Cholelithiasis involves the presence of gallstones (see the image below), 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.

Magnetic resonance cholangiopancreatography (MRCP) showing 5 gallstones in the common

bile duct (arrows). In this image, bile in the duct appears white; stones appear as dark-filling
defects. Similar images can be obtained by taking plain radiographs after injection of
radiocontrast material in the common bile duct, either endoscopically (endoscopic retrograde
cholangiography) or percutaneously under fluoroscopic guidance (percutaneous transhepatic
cholangiography), but these approaches are more invasive.

However, about 15 percent of all people with gallstones will have gallstones in the bile duct, or
choledocholithiasis, according to research published in The Medical Clinics of North America.

In general, women are probably at increased risk because estrogen stimulates the liver to remove
more cholesterol from blood and divert it into the bile.

Estrogen raises triglycerides, a fatty acid that increases the risk for cholesterol stones.

Symps: The pain caused by gallstones in the bile duct can be sporadic, or it can linger. The pain
may be mild at times and then suddenly severe. Severe pain may require emergency medical
treatment. The most severe symptoms may be confused with a cardiac event like a heart attack.

When a gallstone is stuck in the bile duct, the bile can become infected. The bacteria from the
infection can spread rapidly, and may move into the liver. If this happens, it can become a life-
threatening infection. Other possible complications include biliary cirrhosis and pancreatitis.

Even people who have had their gallbladders removed can experience this condition.

In the Philippines, there were 131 males (18%) and 609 (82%) females, with a female ratio male
4.6:1. Benign lesions comprised 99% (mean age 36), mostly chronic cholelithiasis (97%) and
acute cholelithiasis which constituted 15 cases only (2%), malignant lesions comprised only 7
cases for example 1% of all lesions (mean age 65).

According to a 2008 study published in The Medical Clinics of North America, bile duct stones
return in 4 to 24 percent of patients during the 15-year period after they first occur. Some of
these stones may have been left over from the previous episode.

Studies have shown that 10% of those people will develop symptoms within five years of
diagnosis and 20% within 20 years.[2]
 DIAGNOSIS

Complete blood count (CBC): Which looks at levels of different types of blood cells such

as white blood cells. A high white blood cell count may indicate infection.
Blood test: Levels of Liver enzymes (LTs), which are

blood tests that can show evidence of gallbladder

disease.
Pancreatic enzymes: check of the

blood's amylase or lipase levels to look

for inflammation of the pancreas.

Urine tests may also be performed to help diagnose problems with the

gallbladder by looking for abnormal levels of chemicals like amylase

TREATMENT

stone extraction
fragmenting stones (lithotripsy)
surgery to remove the gallbladder and stones (cholecystectomy)
surgery that makes a cut into the common bile duct to remove stones or help them pass
(sphincterotomy)
biliary stenting
The most common treatment for gallstones in the bile duct is biliary endoscopic sphincterotomy
(BES). During a BES procedure, a balloon- or basket-type device is inserted into the bile duct
and used to extract the stone or stones. About 85 percent of bile duct stones can be removed with
BES.
If a stone does not pass on its own or cannot be removed with BES, doctors may use lithotripsy.
This procedure is designed to fragment stones so they can be captured or passed easily.

Patients with gallstones in the bile duct and gallstones still in the gallbladder may be treated by
removing the gallbladder. While performing the surgery, your doctor will also inspect your bile
duct to check for remaining gallstones.

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If stones cannot be removed completely or you have a history of gallstones causing problems but
do not wish to have your gallbladder removed, your doctor may place biliary stents (tiny tubes to
open the passage). These will provide adequate drainage and help prevent future
choledocholithiasis episodes. The stents can also prevent infection.

Treatment[edit]

Fluoroscopic image taken during ERCP. Multiple gallstones are present in the gallbladder
and cystic duct. The common bile duct and pancreatic duct appear to be patent.
Treatment involves an operation called a choledocholithotomy, which is the removal of the
gallstone from the bile duct using ERCP, although surgeons are now increasingly
using laparoscopy with cholangiography. In this procedure, tiny incisions are made in the
abdomen and then in the cystic duct that connects the gallbladder to the bile duct, and a thin tube
is introduced to perform a cholangiography. If stones are identified, the surgeon inserts a tube
with an inflatable balloon to widen the duct and the stones are usually removed using either a
balloon or tiny basket.
If laparoscopy is unsuccessful, an open choledocholithotomy is performed. This procedure may
be used in the case of large stones, when the duct anatomy is complex, during or after some
gallbladder operations when stones are detected, or when ERCP or laparoscopic procedures are
not available.[3]
Typically, the gallbladder is then removed, an operation called cholecystectomy, to prevent a
future occurrence of common bile duct obstruction or other complications.[4]

References
Fogel EL, Sherman S. Diseases of the gallbladder and bile ducts. In: Goldman L, Schafer AI,
eds. Goldman's Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 155.
Jackson PG, Evans SRT. Biliary system. In: Townsend CM, Beauchamp RD, Evers BM, Mattox
KL. Sabiston Textbook of Surgery. 18th ed. St. Louis, MO: WB Saunders; 2012:chap 55.

5,073,040 WARNING! (Details) 86,241,6972

Prevalence, pop estimated used

About Bile Ducts

The bile ducts carry bile, a liquid the liver makes to help break down food. A group of small bile
ducts called the biliary tree in the liver empties bile into the larger common bile duct. Between
meals, the common bile duct closes and bile collects in the gallbladder a pear-shaped sac next to
the liver.

The pancreatic ducts carry pancreatic juice, a liquid the pancreas makes to help break down food.
A group of small pancreatic ducts in the pancreas empties into the main pancreatic duct.

The common bile duct and the main pancreatic duct join before emptying their contents into
the duodenum through the papillary orifice at the end of the duodenal papilla a small, nipple-
like structure that extends into the duodenum. NIH - National Institute for Diabetes and
Digestive and Kidney Diseases

http://www.nytimes.com/health/guides/disease/choledocholithiasis/risk-factors.html
http://img.medscape.com/pi/iphone/medscapeapp/html/A172216-business.html
http://digestive.niddk.nih.gov/statistics).
(Schirmer BD, Winters KL, & Edlich RF., 2005).