CHOLELITHIASIS

• Cholelithiasis is the presence of gallstones, which are concretions that

form in the biliary tract, in the gallbladder.
• Choledocholithiasis refers to the presence of one or more gallstones
in the common bile duct (CBD).
• Gallstone disease may be thought of as having the following four
stages:
-Lithogenic state, in which conditions favor gallstone formation
-Asymptomatic gallstones
-Symptomatic gallstones, characterized by episodes of biliary colic
-Complicated cholelithiasis
 PATHOPHYSIOLOGY
• Cholesterol stones account for > 85% of gallstones

• For cholesterol gallstones to form, the following is required:

• Bile must be supersaturated with cholesterol. In normal condition
water-insoluble cholesterol is made water soluble by combining with
bile salts and lecithin to form mixed micelles.

• Supersaturation of bile with cholesterol most commonly results from

excessive cholesterol secretion (as occurs in obesity or diabetes)
and decrease in bile salt secretion or in lecithin secretion

• When gallbladder is supersaturated with these substances, which

then precipitate from the solution as microscopic crystals trapped in
the gallbladder mucus, producing gallbladder sludge. Over time they
fuse to form macroscopic stones.

• Occlusion of the ducts by sludge and/or stones produces the

complications of gallstone disease.
• Black pigment stones are small, hard gallstones composed of calcium bilirubinate
and inorganic Ca salts. Factors that accelerate stone development include
alcohol-related liver disease, chronic hemolysis, and older age.

• Brown pigment stones are soft and greasy, consisting of bilirubinate and fatty
acids (Ca palmitate or stearate). They form during infection, inflammation, and
parasitic infestation.
RISK FACTORS
Gender - caused by the higher amount of hormone oestrogen found in women.
Certain conditions in women expose them to an even higher amount of oestrogen
such as pregnancy, hormone replacement therapy and birth control pills. Excess
oestrogen increases cholesterol level in bile. Excess oestrogen also decreases
gallbladder contractility leading to bile stasis and gallstones formation

Weight - higher cholesterol levels in the blood

Diet - Diet high in fats and cholesterol

Age - Elderly individuals above the age of 60 have higher incidence of gallstones
 SIGN & SYMPTOMS
Asymptomatic gallstones
• Gallstones may be present in the gallbladder for decades without causing symptoms or complications.
It may be found as an incidental finding during a routine investigation
Biliary colic
• occurs when gallstones impact in the cystic duct during gallbladder contraction, increasing the
gallbladder wall tension. In most cases, the pain resolves over 30 to 90 minutes as the gallbladder
relaxes and the obstruction is relieved.
• Episodes of biliary colic are sporadic and unpredictable. The patient localizes the pain to the
epigastrium or right upper quadrant and may radiate to the right scapular tip
• The pain begins postprandially after a fatty meal, is often described as intense and dull.
• From the onset, the pain increases steadily and then gradually wanes when the gallbladder stops
contracting and the stone falls back into the gallbladder.
• The pain is constant in nature and is not relieved by emesis, antacids, defecation, flatus, or positional
changes. It may be accompanied by nausea, and vomiting.
• in uncomplicated biliary colic, the pain is poorly localized and visceral in origin
• In acute cholecystitis, may present with fever and well-localized pain in the
right upper quadrant, usually with rebound and guarding. A positive Murphy is
highly suggestive of cholecystitis

• The presence of fever, persistent tachycardia, hypotension, or jaundice

necessitate a search for complications of cholelithiasis, including cholecystitis,
cholangitis, pancreatitis, or other systemic causes.

• Choledocholithiasis with obstruction of the common bile duct produces

cutaneous and scleral icterus that evolves over hours to days as bilirubin
accumulates.

• The Charcot triad of severe right upper quadrant tenderness with jaundice and
fever is characteristic of ascending cholangitis.
BLOOD INVESTIGATION
Laboratory studies recommended for patients with suspected
complications of gallstones include:
• FBC - often have mild leukocytosis, the absence of leukocytosis does
not exclude the diagnosis
• LFT – Abnormal findings on liver function testing also occur in patients
with cholecystitis, as well as in patients with cholangitis. ALP & GGT
are more concentrated in the biliary ducts where as AST & ALT are
found in the hepatic cells
• Amylase/lipase - Elevated amylase and lipase levels raise suspicion for
gallstone pancreatitis
 IMAGING
Ultrasonography • Inexpensive
• Noninvasive
• First-line test for patients with suspected gallstones or acute
cholecystitis
• Provides anatomic information, such as presence of polyps,
common bile duct diameter, and parenchymal hepatic
abnormalities

Computed • Superior to ultrasonography in visualizing the biliary tree and

tomography distal common bile duct
• Higher cost and radiation exposure make it a second-line
option to ultrasonography
MANAGEMENT
• Asymptomatic gallstones may be
managed expectantly

• Once gallstones become

symptomatic, definitive surgical
intervention with cholecystectomy is
usually indicated typically,
laparoscopic cholecystectomy for the
following:
-Small stone size (< 0.5 to 1 cm)
-Good gallbladder function (eg, normal
filling and emptying)
-Minimal or no calcification

• Open surgery may be indicated in

patients with complicated
cholecystitis
REFERENCES
• https://www.aafp.org/afp/2014/0515/p795.html
• https://emedicine.medscape.com/article/175667