Scribd
Upload
34 views

Reading 4 Gallstones

Uploaded by

Aron Enrique
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
34 views

Reading 4 Gallstones

Uploaded by

Aron Enrique
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

Session 4

GALLSTONES
Gallstones or cholelithiasis are responsible for one of the most prevalent digestive disorders in
the United States. They are considered a disease of developed populations but are present
around the world. It is both the result of a chronic disease process and the cause of subsequent
acute disorders of the pancreatic, biliary, hepatic, and gastrointestinal tract. Most patients with
gallstones are asymptomatic, but 10% of patients will develop symptoms within five years, and
20% of patients will develop symptoms within 20 years of diagnosing gallstones. Gallstone
prevalence also increases with age. Over one-quarter of females older than the age of 60 will
have gallstones.

The critical feature of gallstones is that they are not all symptomatic. Sometimes they may
migrate near the opening of the cystic duct and block the flow of bile. This can lead to tension
in the gallbladder, which results in the classic biliary colicky pain. If the cystic duct is obstructed
for more than a few hours, it can lead to inflammation of the gallbladder wall (cholecystitis).
Sometimes the gallstone may move into the bile duct and cause obstruction, leading to jaundice
and abdominal pain. Patients who have chronic gallstones may develop progressive fibrosis and
loss of motor function of the gallbladder.

Causes

Gallstones usually form from sluggishly emptying of bile from the gallbladder. When bile is not
fully drained from the gallbladder, it can precipitate as sludge, which in turn can develop into
gallstones. Biliary obstruction from various causes such as strictures in the bile duct or
neoplasms may also lead to gallstones. The most common cause of cholelithiasis is the
precipitation of cholesterol from cholesterol-rich bile. The second most common form of
gallstones is pigmented gallstones. These form from the breakdown of red blood cells and are
black. The third type of gallstones is mixed pigmented stones, a combination of calcium
substrates such as calcium carbonate or calcium phosphate, cholesterol, and bile. The fourth
type of stone is calcium stones. These may be due to the precipitation of serum calcium
in patients with hypercalcemia. Often these patients will have concurrent kidney stones.
Session 4

Risk Factors

• In pregnancy, progesterone decreases the contractility of the gallbladder leading to


stasis
• Obesity
• Genes
• Certain medications (estrogens, fibrates, somatostatin analogs)
• Stasis of the gallbladder
• Female gender
• Metabolic syndrome
• Rapid weight loss
• Prolonged fasting
• Bariatric surgery
• Crohn disease, ileal resection
Symptoms

Usually, patients with symptoms from gallstones present with right upper abdominal pain after
eating greasy or spicy foods. There is often nausea and vomiting. Pain can also be present in the
epigastric area that radiates to the right scapula or mid-back. The classic physical exam finding is
a positive Murphy's sign, where the pain is elicited on deep palpation to the right upper quadrant
underneath the rib cage upon deep inspiration. Patients may be asymptomatic for months to
years until the discovery of gallstones. Acute cholecystitis presents similarly. However, it is more
severe. Jaundice can be a sign of a common bile duct obstruction from an entrapped
gallstone. In the presence of jaundice and abdominal pain, often, a procedure is an indication to
go and retrieve the stone to prevent further sequelae. One such sequela is ascending cholangitis,
with symptoms of right upper abdominal pain, fever, and jaundice (Charcot's triad). Progression
of this condition is indicated by neurologic changes and hypotension (Reynold's pentad). Other
sequelae are acute pancreatitis with symptoms of mid-epigastric pain and intractable vomiting.

Evaluation

The best diagnostic test for diagnosing gallstones and subsequent acute cholecystitis is a right
upper quadrant abdominal ultrasound. It is associated with a 90% specificity rate and,
depending on the ultrasound operator, can detect stones as small as 2 mm as well as sludge and
gallbladder polyps. Ultrasound findings that point towards acute cholecystitis versus
cholelithiasis include gallbladder wall thickening greater than 3 mm, pericholecystic fluid, and a
positive sonographic Murphy's sign. Gallstones can also often be present on CT scans and MRIs.
However, these tests are not as sensitive for diagnosing acute cholecystitis. Approximately 10%
of gallstones may be found on routine plain films due to their high calcium content. If there is a
suspected stone in the common bile duct based on ultrasound results, magnetic resonance
cholangiopancreatography (MRCP) is the next step. If a common duct stone is identified on the
MRCP, then the gold-standard test of an endoscopic retrograde cholangiopancreatogram (ERCP)
should be performed by a gastroenterologist. A percutaneous transhepatic cholangiogram
(PTHC) is also useful in diagnosing common bile duct stones if an ERCP is not possible.
Session 4

Treatment

Cholecystectomy treats symptomatic gallstones. The laparoscopic approach is the standard of


care. Open cholecystectomies are the option when it is not practical or advisable to do a
laparoscopic procedure. It is not wise to only remove the gallstones as studies have shown that
they recur after about one year. In cases of acute cholecystitis in critically ill patients or patients
who are poor surgical candidates, a decompression cholecystostomy tube can be placed to
temporize the patient until stable enough for definitive surgery. Common bile duct stones can
be removed with a preoperative or postoperative ERCP, PTHC, or operatively with a common
bile duct exploration. Ascending cholangitis needs to be addressed urgently by removing the
blockage either with ERCP, PTHC, or surgery, as well as early antibiotic administration. In cases
of nonacute cholecystitis and very poor surgical candidates, gallstones can be treated medically.
Ursodiol is administered daily with the hope of dissolving the gallstones and has shown mixed
success with some studies at best, showing less than a 50% response rate.
Session 4

THE DIGESTIVE SYSTEM

You might also like