Cholelithiasis

Choleliths (gallstones) are crystalline bodies that form in the biliary tree when bile components
aggregate and undergo concretion. Stones can occur anywhere in the biliary tree. When a stone
forms in the gallbladder, it is called cholecystolithiasis. When a stone forms in the common bile
duct, it is called choledocholithiasis.

Stones vary in size from grainy, sludge-like bile to golf ball sized calculi, and can occur as a
single large stone or multiple stones. There are two types of cholelith based on content:

1. Cholesterol stones: These are green, white, or yellow stones that are made mostly
(70-80%) of cholesterol, with calcium salts and bilirubin compounds making up
the other 20-30%. These occur because the bile contains too much cholesterol and
not enough bile salts. Other contributing factors include inefficient and infrequent
gallbladder contractions, which allow bile to sit in the gallbladder for long periods
of time, resulting in an over concentrated bile that is conducive to stone
formation. No clear link between diet and risk for cholelithiasis has been shown,
though it has been suggested that diets high in cholesterol and low in fiber may
increase one's risk. A mnemonic for remembering risk factors for cholesterol
gallstones is the 5 F's: Fat (overweight), Forty (age near or above 40), female,
fertile (premenopausal- increased estrogen is thought to increase cholesterol
levels in bile and decrease gallbladder contractions), and fair (gallstones more
common in Caucasians).
 Cholesterol Gallstones

2.

3. Pigment stones: Dark stones, usually small, that contain less than 20% cholesterol
and are composed mainly of bilirubin and calcium salts. Risk factors include
those disorders that result in excessive bilirubin production, such as hemolytic
anemia (when hemoglobin is liberated from red blood cells it is broken down and
its heme component is eventually degraded into bilirubin by the liver, which then
uses the bilirubin in bile). Other risk factors are cirrhosis and biliary tract
infections.

Pigment Gallstones
Consequences of Cholelithiasis

Numerous clinical consequences and pathologies arise from cholelithiasis. Here

are some of the major consequences and treatment options:

1. Cholecystitis - This term means inflammation of the gallbladder, and it is

most commonly caused by choleliths, though an acalculous (without
gallstones) form can occur in debilitated and trauma patients. Typically a
gallstone will form in the gallbladder and move into the cystic duct where
it occludes the lumen and prevents bile from exiting the gallbladder. This
leads to thickening of the bile, bile stasis, and secondary infection by gut
organisms such as E. coli and Bacteroides species. The gallbladder lining
consequently becomes inflamed, potentially progressing to irritation of the
surrounding tissue (bowel, diaphragm), necrosis, or rupture.
Cholecystoliths can cause either acute attacks or chronic, low-level
inflammation that results in a fibrotic and calcified gallbladder.

A less common but clinically interesting scenario is when the

gallbladder becomes inflamed and adheres to a section of bowel. If
the gallbladder ruptures it can form a fistula with a section of
bowel, which allows choleliths to pass into the bowel resulting in a
gallstone ileus (see beginning of Dr. Ramsburgh Histopathology
lecture Neoplasia II).

Though non-invasive therapies do exist, definitive treatment for

cholecystitis is cholecystectomy (surgical removal of gallbladder).

2. Choledocholithiasis - The presence of gallstones in the common bile duct

is a medical emergency because it impedes the flow of bile from the liver
to the duodenum, resulting in jaundice and liver cell damage subsequent to
increased alkaline phsophatase, conjugated bilirubin, and cholesterol in the
blood (as bile backs up into the liver, bile products and liver enzymes
begin rising in the blood). Diagnosis is dependent first on diagnosing
cholelithiasis (if no stones are present, stones can't be blocking the
common bile duct). Often a procedure called ERCP (endoscopic
retrograde cholangiopancreatography) is done to both confirm the
diagnosis of choledocholithiasis and provide treatment. This procedure
involves passing an endoscopic orally into the duodenum where the
hepatopancreatic ampulla (ampulla of Vater) opens to the main pancreatic
and bile ducts. If a stone is seen obstructing the biliary tree, it can
sometimes be removed by the endoscope as it widens the duct lumen,
allowing the stone to be passed into the duodenum.

3. Pancreatitis - The most common cause of acute pancreatitis is gallstones

(alcohol is the most common cause of chronic pancreatitis). Gallstones
cause pancreatitis when they pass out of the gallbladder, down the
 common bile duct, and become lodged so as to obstruct the outflow of the
pancreatic exocrine system at the main pancreatic duct. ERCP (endoscopic
retrograde cholangiopancreatography- see #2 above) can be used to
diagnose and treat acute pancreatitis that is caused by choledocholithiasis.

Choleliths on CT Scan

Due to their high calcium salt content, gallstones appear as highly attenuated
(very white, like bone) calculi on CT scans. The gallbladder is tucked underneath
the liver between the quadrate and right lobes. The image below shows the
gallbladder's location as viewed anteriorly.
We must look at the gallbladder in axial cross-section on CT scan, however, so
study the image below to get comfortable with the level of the gallbladder in the
abdomen. Notice that the gallbladder may be seen next to sections of liver,
stomach, pancreas, bowel, kidney, and spleen (a very busy cross-section to study).
The movie file below is the CT scan of cadaver 33487. Move the scan to time 68-
70 which is at the L1-L2 level. Try and orient yourself to the liver (H7-H12) and
the superior pole of the right kidney (J11). The gallbladder is a low attenuation
sac located to the left of the liver (patient's left) and above (anterior to) the kidney.
This gallbladder is made easier to see by the presence of a gallstone, visible at
time 68-70, J10. Just to the left (patient's left) of the gallstone is the head of the
pancreas. Scan just below the gallstone and you will see that areas of the head of
the pancreas are also calcified, indicating that this patient possibly suffered from
chronic pancreatitis.