GALLSTONES

AFIF BIN AIDIT 082013100004 IMS BANGALORE

LEARNING OUTCOMES
Definition of gallstones

Types of gallstones
Factors causing gallstones Features of gallstones

Investigations of gallstones
Treatment of gallstones

DEFINITION
Gallstone formation is most common disorder of

biliary tree Presence of stone in biliary tract is called gallstone or cholelithiasis Commonly associated with 5 Fs : female, forty, fertile, fair and fat Either cholesterol gallstones or pigment stones

PATHOPHYSIOLOGY
Cholesterol gallstones

- Cholesterol is held in solution in bile

- By its association with bile acids and phospholipids -

in form of micelles and vesicles Biliary lipoproteins have a role in solubilizing cholesterol In gallstone disease, liver produces bile Contains an excess of cholesterol Either a relative deficiency of bile salts or relative excess of cholesterol

- Bile which is supersaturated with cholesterol is

termed lithogenic
Factors leading to production of lithogenic bile 1) Defective bile salt synthesis 2) Excessive intestinal loss of bile salts 3) Over-sensitive bile salt feedback 4) Excessive cholesterol secretion 5) Abnormal gallbladder function

- Nucleation factors are factors initiating -

crystallization of cholesterol in lithogenic bile Patients with cholesterol gallstones have gallbladder bile which forms cholesterol crystals rapidly than equally saturated bile from patients who do not form gallstones Nucleation factors include mucus, calcium, fatty acids Anti-nucleation factors are apolipoproteins

RISK FACTORS FOR CHOLESTROL GALLSTONES

Increase cholesterol secretion 1) Old age 2) Female 3) Pregnancy 4) Obesity Impaired gallbladder emptying 1) Pregnancy 2) Gallbladder stasis 3) Fasting 4) Total parenteral nutrition 5) Spinal cord injury Decrease bile salt secretion 1) Pregnancy

5) Rapid weight loss

 Pigment stones

- Brown crumbly pigment stones usually caused due to

consequence of bacterial or parasitic infection in biliary tree - Infection of biliary tree allows bacterial betaglucuronidase to hydrolyse conjugated bilirubin to its free form - Then precipitates as calcium bilirubinate

COMPOSITION OF PIGMENT STONES

Black 1) Polymerised calcium 2) Bilirubinates 3) Mucin glycoprotein 4) Calcium phosphate 5) Calcium carbonate 6) Cholesterol Brown 1) Calcium bilirubinate 2) Crystals 3) Mucin glycoprotein 4) Cholesterol 5) Calcium palmitate/steara te

Composition

RISK FACTORS OF PIGMENT STONES

Black Brown 1) Haemolysis 1) Infected bile 2)Age 2)stasis 3)Hepatic cirrhosis 4)Ileal resection

Risk factors

CLINICAL FEATURES
Majority of gallstones are asymptomatic Symptomatic stones within the gallbladder manifest as

either biliary pain or cholecystitis If gallstone becomes acutely impacted in cystic duct, patient will experience pain Typically the pain occurs suddenly and persists up to 2 hours Up to 6 hours, cholecystitis or pancreatitis may be present Pain usually felt in epigastrium (70%) or right upper quadrant (30%)

INVESTIGATIONS
Ultrasound (transabdominal ultrasound)

MRCP
CT scan

 Medical dissolution of gallstone can be attempted

Long-term oral administration of bile acid

ursodeoxycholic acid Should consider in those with : 1) Radiolucent gallstones 2) Stones smaller than 15mm diameter 3) Moderate obesity 4) No or at most mild symptoms

MANAGEMENT
Gallbladder stones 1) Cholecystectomy : Open or laparoscopic 2)Oral bile acids : chenodeoxycholic Bile duct stones 1) Lithotripsy (endoscopic) 2)Endoscopic sphincterotomy and balloon trawl 3)Surgical bile duct

COMPLICATIONS OF GALLSTONES
1) Empyema of gallbladder

2) Choledolithiasis
3) Acute pancreatitis 4) Cancer of gallbladder

5) Mirizzis syndrome

REFERENCE
G.K Pal, Textbook of Medical Physiology 2th Edition

Davidsons Principles And Practice Of Medicine 21st

Edition