Cholelithiasis Is the Formation of Gallstones, Which Are Composed of Cholesterol, Calcium

Cholelythiasis

1. Cholelythiasis. Clinical picture. Methods of patient examination.
2. Complications of cholelythiasis (mechanical, infectious, degenerative). Treatment.
3. Mechanical jaundice. Differential diagnosis. Treatment.

Cholelithiasis is the formation of gallstones, which are composed of cholesterol, calcium salts, and bile pigments

A gallstone is a crystallineconcretion formed within the gallbladder by accretion of bile components. Presence of stones in the gallbladder is referred to as cholelithiasis (from the Greek: chol-, "bile" + lith-, "stone" + iasis-, "process").

Characteristics and composition

Gallstones can vary in size from as small as a grain of sand to as large as a golf ball. The gallbladder may contain a single large stone or many smaller ones. Pseudoliths, sometime referred to as sludge, are thick secretions that may be present within the gallbladder, either alone or in conjunction with fully formed gallstones. The clinical presentation is similar to that of cholelithiasis. The composition of gallstones is affected by age, diet and ethnicity. On the basis of their composition, gallstones can be divided into the following types:

Cholesterol stones

Cholesterol stones vary in color from light-yellow to dark-green or brown and are oval 2 to 3 cm in length, often having a tiny dark central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese classification system).

Pigment stones are small, dark stones made of bilirubin and calciumsalts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese classification system).

Mixed stones

Mixed gallstones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin, and other bile pigments. Because of their calcium content, they are often radiographically visible

Cholelithiasis - Causes, Symptoms And Treatment

Diseases of the gallbladder and biliary tract are common and, in many cases, painful conditions that may be life threatening and usually require surgery. They are generally associated with deposition of calculi and inflammation.

Cholelithiasis is the fifth leading cause of hospitalization among adults and accounts for 90% of all gallbladder and duct diseases. Women have two to three times the incidence as men of developing cholelithiasis. The disease may also be more prevalent in persons who are obese, who have high cholesterol, or who are on cholesterol lowering drugs. The prognosis is usually good with treatment unless infection occurs, in which case prognosis depends on its severity and response to antibiotics.

In most cases, gallbladder and bile duct diseases occur during middle age. Between ages 20 and 50, they're six times more common in women, but incidence in men and women becomes equal after age 50. Incidence rises with each succeeding decade.

Causes of Cholelithiasis

Cholelithiasis stones or calculi (gallstones) in the gallbladder. results from changes in bile components. Gallstones are made of cholesterol, caldurn bilirubinate, or a mixture of cholesterol and bilirubin pigment. They arise during periods of sluggishness in the gallbladder due to pregnancy. hormonal contraceptives. diabetes mellitus. celiac disease, cirrhosis of the liver, and pancreatitis.

One out of every 10 patients with gallstones develops Cholelithiasis, or gallstones in the common bile duct (sometimes called common duct stones). This condition occurs when stones pass out of the gallbladder and lodge in the hepatic and common bile ducts. obstructing the flow of bile into the duodenum. Prognosis is good unless infection occurs.

Cholangitis, infection of the bile duct, is commonly associated with choledocholithiasis and may follow percutaneous transhepatic cholangiography or occlusion of endoscopicstents. Predisposing factors may include bacterial or metabolic alteration of bile acids. Widespread inflammation may cause fibrosis and stenosis of the common bile duct. The prognosis for this rare condition is poor without stenting or surgery.

Cholecystitis. acute or chronic inflammation of the gallbladder. is usually associated with a gallstone impacted in the cystic duct, causing painful distention of the gallbladder. Cholecystitis accounts for 10% to 25% of all patients requiring gallbladder surgery. The acute form is most common during middle age; the chronic form occurs most commonly among the elderly. The prognosis is good with treatment.

Cholesterolosis. polyps or crystal deposits of cholesterol in the gallbladder's submucosa, may result from bile secretions containing high concentrations of cholesterol and insufficient bile salts. The polyps may be localized or speckle the entire gallbladder. Cholesterolosis the most common pseudotumor. isn't related to widespread inflammation of the mucosa or lining of the gallbladder. The prognosis is good with surgery.

Biliary cirrhosis. ascending infection of the biliary system, sometimes follows viral destruction of liver and duct cells. but the primary cause is unknown. This condition usually leads to obstructive jaundice and involves the portal and periportal spaces of the liver. It's nine times more common among women ages 40 to 60 than among men. The prognosis is poor without liver transplantation.

Gallstone ileus results from a gallstone lodging at the terminal ileum; it's more common in the elderly. The prognosis is good with surgery.

Postcholecystectomy syndrome commonly results from residual gal1stones or stricture of the common bile duct. It occurs in 1 % to 5 % of all patients whose gallbladders have been surgical1y removed and may produce right upper quadrant abdominal pain, biliary colic, fatty food intolerance, dyspepsia. and indigestion. The prognosis is good with selected radiologic
procedures, endoscopic procedures, or surgery.

Acalculous cholecystitis is more common in critical1y ill patients, accounting for about 5% of cholecystitis cases. It may result from primary infection with such organisms as Salmollella typhi. Escherichia coli, or Clostridium or from obstruction of the cystic duct due to lymphadenopathy or a tumor. It appears that ischemia usually related to a low cardiac output. also has a role in the pathophysiology of this disease. Signs and symptoms of acalculous cholecystitis include unexplained sepsis, right upper quadrant pain, fever, leukocytosis, and a palpable gallbladder.

Cholelithiasis Symptoms and Signs

Although gallbladder disease may produceno symptoms. acute cholelithiasis, acute cholecystitis, choledocholithiasis. and cholesterolosis produce the symptoms of a classic gallbladder attack. Attacks commonly follow meals rich in fats or may occur at night. suddenly awakening the patient. They begin with acute abdominal pain in the right upper quadrant that may radiate to the back. between the shoulders. or to the front of the chest; the pain may be so severe that the patient seeks emergency department care. Other features may include recurring fat intolerance. biliary colic. belching. flatulence, indigestion. diaphoresis. nausea. vomiting. chills. low-grade fever. jaundice (if a stone obstructs the common bile duct). and clay-colored stools (with choledocholithiasis).
Clinical features of cholangitis include a rise in eosinophils, jaundice, abdominal pain. high fever. and chills; biliary drrhosis may produce jaundice, related itching, weakness, fatigue. slight weight loss. and abdominal pain. Gallstone ileus produces signs and symptoms of small bowel obstruction - nausea. vomiting, abdominal distention, and absent bowel sounds if the bowel is completely obstructed. Its most telling symptom is intermittent recurrence of colicky pain over several days. Each of these disorders produces its own set of complications.

Diagnosis and testing information

Differential diagnosis is essential in gallbladder and biliary tract disease because gallbladder disease can mimic other diseases (myocardial infarction. angina. pancreatitis. pancreatic head cancer. pneumonia, peptic ulcer, hiatal henda, esophagitis. and gastritis). Serum amylase distinguishes gallbladder disease from pancreatitis. With suspected heart disease. serial cardiac enzyme tests and electrocardiogram should precede gallbladder and upper GI diagnostic tests. Tests used to diagnose gallbladder and biliary tract disease include:

• Ultrasound reflects stones in the gallbladder with 96% accuracy. It's also considered the primary tool for diagnosing cholelithiasis.
• Percutaneous trashepatic cholangiography. done under fluoroscopic control. distinguishes between gallbladder or bile duct disease and cancer of the pancreatic head in patients with jaundice.
• Endoscopic retrograde cholangiopancreatography (ERCP) visualizes the biliary tree after insertion of an endoscope down the esophagus into the duodenum, cannulation of the common bile and pancreatic ducts, and injection of contrast medium.
• HIDA scan of the gallbladder detects obstruction of the cystic duct.
• Computed tomography scan, although not used routinely, helps distinguish between obstructive and non obstructive jaundice.
• Flat plate of the abdomen identifies calcified, but not cholesterol. stones with 15% accuracy.
• Oral cholecystography, which is rarely used, shows stones in the gallbladder and biliary duct obstruction.

Elevated icteric index, total bilirubin, urine bilirubin, and alkaline phosphatase support the diagnosis. White blood cell count is slightly elevated during a cholecystitis attack.

Cholelithiasis treatment

Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients must be indicated to surgery. The lack of a gallbladder may have no negative consequences in many people. However, there is a portion of the population — between 10 and 15% — who develop a condition called postcholecystectomy syndrome which may cause gastrointestinal distress and persistent pain in the upper-right abdomen, as well as a 10% chance of developing chronic diarrhea.

Surgery, usually elective, is the treatment of choice for gallbladder and biliary tract diseases and may include open or laparoscopic cholecystectomy, cholecystectomy with operative cholangiography and, possibly, exploration of the common bile duct.

There are two surgical options for cholecystectomy:

• Open cholecystectomy: This procedure is performed via an incision into the abdomen (laparotomy) below the right lower ribs. Recovery typically consists of 3–5 days of hospitalization, with a return to normal diet a week after release and normal activity several weeks after release.

Laparoscopic cholecystectomy: This procedure, introduced in the 1980s, is 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. Laparoscopic cholecystectomy patients can, in general, resume normal diet and light activity a week after release, with some decreased energy level and minor residual pain continuing for a month or two. Studies have shown that this procedure is as effective as the more invasive open cholecystectomy, provided the stones are accurately located by cholangiogram prior to the procedure so that they can all be removed.

Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP).

Other treatments include a low-fat diet to prevent attacks and vitamin K for itching, jaundice, and bleeding tendendes due to vitamin K deficiency. Treatment during an acute attack may include insertion of a nasogastric tube and an I.V.line and, possibly, antibiotic and analgesic administration.A non surgical treatment for choledocholithiasis involves placement of a catheter through the percutaneous transhepatic cholangiographic route. Guided by fluoroscopy, the catheter is directed toward the stone. A basket is threaded through the catheter,opened, twirled to entrap the stone, closed, and withdrawn. This procedure can be performed endoscopically.

Ursodiol (Actigall), which dissolves radiolucent stones, provides an alternative for patients who are poor surgical risks or who refuse surgery. however, use of urdodiol is limited by the need for prolonged treatment, the high incidence of adverse effects, and the frequency of stone formation after the treatment ends.

Extra corporeal shock wave lithotrillsy (ESWL) has also been adapted for the treatment of gallstones. ESWL Is a non surgical procedure used to ('rush stones inside the gallbladder. Gallstones can be broken up using a procedure called extracorporeal shock wave lithotripsy (often simply called "lithotripsy"), which is a method of concentrating ultrasonic shock waves into the stones to break them into tiny piecesthat can pass out of the gallbladder through the cystic duct and common bile duct into
the small intestine.

Jaundice-(jôn`dĭs, jän`–), abnormal condition in which the body fluids and tissues, particularly the skin and eyes, take on a yellowish color as a result of an excess of bilirubin. During the normal breakdown of old erythrocytes (red blood cells), their hemoglobin is converted into bilirubin. Normally the bilirubin is removed from the bloodstream by the liver, which passes from the liver into the intestines.There are several conditions that may interrupt the elimination of bilirubin from the blood and cause jaundice.

Prehepatic jaundice is caused by an increased content of free bilirubin circulating in the blood, formed as a result of increased decomposition of the erythrocytes (hemolytic jaundice), or of congenital or acquired deficiency of enzymes that participate in binding bilirubin with glucuronic acid. Hemolytic jaundice appears in hemolytic disease of the new-born and in poisoning with hemolytic toxins; it is characterized by increased excretion of the products of bilirubin metabolism in the urine (urobilin) and feces (stercobilin, which causes the saturated pigmentation of the feces). Other types of jaundice caused by disruption in the capture and bonding of bilirubin and proceeding without substantive affection of liver cells are physiological jaundice of the new-born, nuclear jaundice, and juvenile jaundice.

Hepatogenic jaundice (parenchymatous jaundice) is a function of organic (infectious, parasitic, or toxic) affection of the liver itself and is conditioned by the formation of an anastomosis between blood and bile capillaries and also by intrahepatic stasis of bile during inflammations of the liver. There appear, along with other symptoms of liver affection, a saturated pigmentation of the urine and faintly colored feces.

Posthepatic, or,Mechanical biliary obstruction.Such obstruction may have a malignant or benign origin. Choledocholithiasis is found in about 15% of patients with gallbladder stones. The clinical presentation ranges from mild right upper quadrant pain with minimal elevation of liver enzymes to ascending cholangitis. Ultrasonography is as sensitive as CT for the detection of choledocholithiasis. ERCP is also highly accurate in the diagnosis of biliary obstruction, with a sensitivity of 89% to 98% and a specificity of 89% to 100%.ERCP can also be used for therapeutic interventions, including stone removal and endobiliary stent placement.

Biliary obstruction may also be caused by parasitic infections (as with Ascarislumbricoides); on endoscopy, the organisms can sometimes be seen protruding from the ampulla.

Malignant causes include carcinoma of the pancreas or gallbladder, ampullary carcinoma, and cholangiocarcinoma. ERCP facilitates procedures such as diagnostic brushings or biopsy in cholangiocarcinoma and ampullary cancer, as well as the placement of an endobiliary stent to temporarily relieve the obstruction. Jaundice in PSC is typically a result of end-stage liver disease; however, occasionally a dominant nonmalignant extrahepatic biliary stricture is the cause, and this condition is treatable with endobiliary stent placement.

In a number of instances, a yellow coloring of the skin and other body tissues may be caused by pigments in food (for example, the carotene contained in carrots) or medications (acrichin).

Choledocholithiasis

If gallstones migrate into the ducts of the biliary tract, the condition is referred to as choledocholithiasis (from the Greek: chol-, "bile" + docho-, "duct" + lith-, "stone" + iasis-, "process").

Signs and symptoms

A positive Murphy's sign is a common finding on physical examination. Jaundice of the skin or eyes is an important physical finding in biliary obstruction. Jaundice and/or clay-colored stool may raise suspicion of choledocholithiasis or even gallstone pancreatitis. If the above symptoms coincide with fever and chills, the diagnosis of ascending cholangitis may also be considered.

Causes

While stones can frequently pass through the common bile duct (CBD) into the duodenum, some stones may be too large to pass through the CBD and may cause an obstruction. One risk factor for this is duodenal diverticulum.

Pathophysiology

This obstruction may lead to jaundice, elevation in alkaline phosphatase, increase in conjugated bilirubin in the blood and increase in cholesterol in the blood. It can also cause acute pancreatitis and ascending cholangitis.

Diagnosis

Common bile duct stone impacted at ampulla of Vater seen at time of ERCP

Choledocholithiasis (stones in common bile duct) is one of the complications of cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of cholelithiasis. Patients with cholelithiasis typically present with pain in the right-upper quadrant of the abdomen with the associated symptoms of nausea and vomiting, especially after a fatty meal. The physician can confirm the diagnosis of cholelithiasis with an abdominal ultrasound that shows the ultrasonic shadows of the stones in the gallbladder.

The diagnosis of choledocholithiasis is suggested when the liver function blood test shows an elevation in bilirubin. The diagnosis is confirmed with either an Magnetic resonance cholangiopancreatography (MRCP), an ERCP, or an intraoperative cholangiogram. If the patient must have the gallbladder removed for gallstones, the surgeon may choose to proceed with the surgery, and obtain a cholangiogram during the surgery. If the cholangiogram shows a stone in the bile duct, the surgeon may attempt to treat the problem by flushing the stone into the intestine or retrieve the stone back through the cystic duct.

On a different pathway, the physician may choose to proceed with ERCP before surgery. The benefit of ERCP is that it can be utilized not just to diagnose, but also to treat the problem. During ERCP the endoscopist may surgically widen the opening into the bile duct and remove the stone through that opening. ERCP, however, is an invasive procedure and has its own potential complications. Thus, if the suspicion is low, the physician may choose to confirm the diagnosis with MRCP, a non-invasive imaging technique, before proceeding with ERCP or surgery.

Treatment

Treatment involves removing the stone using ERCP. Typically, the gallbladder is then removed, an operation called cholecystectomy, to prevent a future occurrence of common bile duct obstruction or other complications