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By: Rey Martino

€ Lies

on the underside of the liver in the main liver scissura at the junction of the right and left lobes of the liver. pear-shaped structure, 7.5²12 cm long, with a normal capacity of about 35²50 ml. divisions are a fundus, a body and a neck that terminates in a narrow infundibulum.


€ Anatomical

Definition ‡ Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. Characteristics and composition ‡ Gallstones can vary in size and shape, can be single large stone or many smaller ones ‡ On the basis of their composition, gallstones can be divided into cholesterol stones, pigment stones or mixed stones.

Cholesterol stones
‡ vary in color from light-yellow to dark-green or brown and are oval 2 to 3 cm in length. ‡ >80% cholesterol by weight ‡ Imbalance in bile between cholesterol, bile salts and phospholipids, producing lithogenic bile.

Pigment stones
‡ Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. ‡ <20% of cholesterol ‡ Chronic hemolysis, biliary tract infections,

Mixed stones
‡ Mixed gallstones typically contain 20²80% cholesterol, other common constituents are calcium carbonate, palmitate phosphate, bilirubin, and other bile pigments. ‡ Because of their calcium content, they are often radiographically visible. ‡ Associated with anatomical abnormalities, stasis, previous surgeries, previous infection


Risk factors
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Female, Forty, Fat, Fertile Bile stasis Chronic hemolysis Oral contraceptives Rapid weight loss Obesity Total parenteral nutrition Ileal resection


Clinical Manifestation ‡ Episodic RUQ/epigastric pain ‡ Usually transient ‡ Colicky ‡ Often postprandial ‡ Radiate to the back, right scapula/right shoulder ‡ Food intolerance (esp. fatty, greasy or fried food) ‡ Dyspepsia, flatulence ‡ Nausea/vomiting ‡ RUQ tenderness and/or a palpable gallbladder may be present

Differential Diagnosis
‡ Cholecystitis ‡ Peptic ulcer disease ‡ Pancreatitis ‡ Cholangitis ‡ Biliary obstruction ‡ Myocardial ischemia

‡ History and physical examination. ‡ FBC, LFT, amylase and lipase. ‡ Ultrasound will directly show gallstone shadows ‡ HIDA scan with CCK stimulation may diagnose biliary dyskinesia and may also be indicated to rule out cystic duct obs. and acute cholecystitis. ‡ Endoscopic retrograde cholangiopancreatography (ERCP) -suspected or proven CBD stones. ‡ CXR and ECG, abdominal x-ray will reveal gallstones in 10% of cases.

Porcelain Single large gall bladder gallstone

gall bladder wall

biliary sludge

Pericholecystic fluid

stone obstructing the common bile duct



Asymptomatic Gallstones
Surgical treatment of asymptomatic gallstones without medically complicating diseases is discouraged risk of complications from interventions is higher than the risk of symptomatic disease


Cholecystectomy for asymptomatic gallstones may be indicated if:
‡ large gallstones (>2 cm diameter) ‡ nonfunctional or calcified (porcelain) gallbladder

observed on imaging studies and who are at high risk of gallbladder carcinoma ‡ spinal cord injuries or sensory neuropathies affecting the abdomen


Patients with risk factors for complications of gallstones may be offered elective cholecystectomy, even if they have asymptomatic gallstones. ‡ Cirrhosis ‡ Portal hypertension ‡ Children ‡ Transplant candidates ‡ Diabetes

€ Medical

dissolution of gallstones

‡ ursodiol (Actigall) and chenodiol (Chenix) work

best for small cholesterol stones
€ Stone

fragmentation (extracorporeal shock wave lithotripsy) to assist stone dissolution and clearance


Symptomatic gallstones Cholecystectomy

Laparoscopic cholecystectomy
Performed via three to four small puncture holes for a camera and instruments. Post-operative care typically includes a same-day release or a one night hospital stay, followed by a few days of home rest and pain medication

ii. Open cholecystectomy x Performed via an incision into the abdomen (laparotomy) below the right lower ribs. Recovery typically consists of 3²5 days of hospitalization, with a return to normal diet a week after release and normal activity several weeks after release



€ Complications

of Laparoscopic Cholecystectomy
‡ Early complication: x Common bile duct injury x Bile leak x Injury to viscera x Hemorrhage x Retained stones and abscess formation ‡ Late complication: x Biliary strictures x Cystic duct clip stones x Hemorrhage