April16, 2020

C) GALLSTONES/ CHOLELITHIASIS

Introduction:
 Gallstones or cholelithiasis rarely occurs in children but the increased use of
ultrasonography has led to increased detection of gallstones in patients.
 Cholelithiasis is sometimes diagnosed in patients incidentally or as silent stones.

Types:

 Children may present with black pigment, cholesterol, calcium carbonate, protein-
dominant or brown pigment stones.
 Black pigment stones are the most common type in children.
 Calcium carbonate stones, which are rare in adults, are more common in children.
 Cholesterol stones are composed of 70-100% cholesterol with an admixture of protein,
bilirubin, and carbonate. Most cholesterol stones are yellow-white in color. These are
most common in adults.
 Brown pigment stones are formed in the presence of biliary stasis and bacterial
infection. They are composed of calcium bilirubinate and the calcium salts of fatty acids
and occur more often in the bile ducts than in the gallbladder.
 Pigment stones are found in hemolytic disease, cirrhosis, bile tract infection, and
hereditary blood disorders, such as spherocytosis and sickle cell anemia. These stones
are black-brown in color and are more common in adolescents.
Etiology:
 There are some predisposing factors like Hemolytic disease, hepatobiliary disease,
obesity, prolonged parenteral nutrition, abdominal surgery, trauma, ileal resection,
Crohn’s disease, sepsis.
 Less prominent risk factors include acute renal failure, prolonged fasting, low-calorie
diets, and rapid weight loss.
 Genetic conditions, such as progressive familial intrahepatic cholestasis type 3, can also
predispose to gallstone formation.
 Defects in the ABCB4 gene have been increasingly recognized in both adults and
children with recurrent cholestasis and cholesterol gallstones.

Pathogenesis:

 The five main constituents of bile include water, bilirubin, cholesterol, bile pigments,
and phospholipids.
 Also, lecithin is the precursor of bile phospholipids.
 The early stage of gallstone formation initiates from the sedimentation of cholesterol,
bile pigments, and calcium salts.
 Imbalance in bile constituents, such as cholesterol, lecithin, and bile salts, is the main
cause of gallstone formation.
 As the concentration of cholesterol increases, the rate of crystallization also elevates,
which gives rise to under lying conditions for gall stone formation.
Clinical features:

 In symptomatic patients: pain in the right upper quadrant (RUQ) or epigastrium. Pain
may radiate to the right shoulder.
 Icterus and pain radiating to the back is suggestive of a stone in common bile duct or
ampulla causing pancreatitis.
 Nausea and vomiting
 Physical examination: Pain in the RUQ is common.
 Murphy sign (patient is not able to exhale during palpation of RUQ) is positive.
 Hepatomegaly and splenomegaly in some cases
 Obesity should also be noted on physical examination, because this can be a risk factor
for the development of cholesterol gallstones.
Diagnosis:
 Complete blood count (CBC)
 Gamma-glutamyl transferase (GGT)
 Amylase: raised level suggest pancreatitis
 Urinalysis
 Serum bilirubin and alkaline phosphatase: raised when the stone is in common bile duct.
 All the above investigations should be within normal limits if there is no obstruction in
the bile duct.
 USG abdomen: shows calculi in the gall bladder and obstruction if there is any.
 Plain radiography, radionuclide scanning is also done.

Treatment:
 In symptomatic cases, the treatment is removal of gallstones either by laparoscopic or
open cholecystectomy (removal of gall bladder).
 If gallstone is located in the common bile duct, it may cause obstruction thus it should
be removed by ERCP (Endoscopic retrograde cholangiopancreatography).
 Asymptomatic cases can be followed up.
 Children with hemolytic diseases should be treated with splenectomy (removal of
spleen) along with cholecystectomy.
Diet: