GALLSTONES

DR: FESTO NGOWI

MD; RESIDENT
OVERVIEW

INTRODUCTION
CHARACTERISTICS
ETIOLOGY
SYMPTOMS
DIAGNOSIS
TREATMENT
INTRODUCTION CONT.

Gallstones (choleliths) are crystalline

bodies formed from bile components.
Gallstones can occur anywhere within
the biliary tree, including the gallbladder
and the common bile duct.
The presence of stones in the
gallbladder or bile ducts is refffered to as
Cholelithiasis.
INTRODUCTION CONT.
Obstruction of the common bile duct is
choledocholithiasis;
Calculous cholecystitis = occlusion of the cystic
duct by gallstone leading to gallbladder
inflammation
Mirizzi syndrome = when gallstones lodged in
either the cystic duct or the Hartmann pouch of
the gallbladder, externally compressed the
common hepatic duct (CHD), causing symptoms
of obstructive jaundice.
INTRODUCTION CONT.

obstruction of the biliary tree can cause

jaundice;
obstruction of the outlet of the pancreatic
exocrine system can cause pancreatitis
CHARACTERISTICS

Size
A gallstone's size can vary and may be
as small as a sand grain or as large as a
golf ball.
The gallbladder may develop a single,
often large stone or many smaller ones.
They may occur in any part of the biliary
system.
CHARACTERISTICS CONT.
Content
Gallstones have different appearance,
depending on their contents.
On the basis of their contents, gallstones can be
subdivided into the two following types:
Cholesterol stones are usually green, but are
sometimes white or yellow in color, made of
cholesterol and calcium salts.
They are made primarily of cholesterol {80%
cholesterol }.
CHARACTERISTICS CONT.

Pigment stones are small, dark stones

made of bilirubin and calcium salts that
are found in bile.

They contain less than 20% of cholesterol.

Risk factors for pigment stones include
hemolytic anemia, cirrhosis, biliary tract
infections, and hereditary blood cell
disorders, such as sickle cell anemia and
spherocytosis.
CHARACTERISTICS CONT.
Mixed stones
All stones are of mixed content to some
extent. Those classified as mixed,
however, contain between 30% and 70%
of cholesterol.
In most cases the other majority
constituent is calcium salts such as
calcium carbonate, palmitate phosphate,
and/or bilirubinate.
CHARACTERISTICS CONT.

Pseudolithiasis
Also know as "Fake stones," they are
sludge-like gallbladder secretions that
act like a stone.
ETIOLOGY

Exact cause not known

Risk factors
Female, Fat, Forty, Fertile
A fifth F, fair indicates that the condition
is more prevalent in Caucasians.
Other Risk factors
Oral contraceptives
Rapid weight loss (gastric bypass pts)
Fatty diet
ETIOLOGY CONT
DM
Hemolytic states
Bile duct stasis (congenital)
Vagotomy
Hyperlipidemia
ETIOLOGY CONT.

Pigment gallstones
Conditions causing hemolytic anemia
can cause pigment gallstones.
ETIOLOGY CONT.

Cholesterol gallstones
Cholesterol gallstones develop when bile
contains too much cholesterol and with no
enough bile salts.
Besides a high concentration of
cholesterol, two other factors seem to be
important in causing gallstones.
ETIOLOGY CONT.
The first is how often and how well the
gallbladder contracts; incomplete and
infrequent emptying of the gallbladder
may cause the bile to become
overconcentrated and contribute to
gallstone formation.
The second factor is the presence of
proteins in the liver and bile that either
promote or inhibit cholesterol
crystallization into gallstones.
ETIOLOGY CONT

In addition, increased levels of the

hormone estrogen as a result of
pregnancy, hormone therapy, or the use
of combined (estrogen-containing) forms
of hormonal contraception, may increase
cholesterol levels in bile and also
decrease gallbladder movement,
resulting in gallstone formation.
Symptoms

Gallstones usually remain asympt initially.

They start developing symptoms once the
stones reach a certain size (>8 mm).
A main symptom of gallstones is commonly
referred to as a gallstone "attack", also
known as biliary colic, in which a person
will experience intense pain in the upper
abdominal region that steadily increases
for approximately thirty minutes to several
hours.
Symptoms

A patient may also experience reffered

pain in the back, ordinarily between the
shoulder blades, or pain under the right
shoulder.
In some cases, the pain develops in the
lower region of the abdomen, nearer to
the pelvis, but this is less common.
Nausea and vomiting may occur.
Symptoms
Patients characteristically exhibit a
positive Murphy's sign: the patient is
instructed to breathe in while the gall
bladder is deeply palpated.
If the gallbladder is inflamed, the patient
will abruptly stop inhaling due to the pain,
a positive Murphy's sign.
Symptoms

These attacks are sharp and intensely

painful, similar to that of a kidney stone
attack.
Often, attacks occur after a particularly
fatty meal and almost always happen at
night.
Other symptoms include abdominal
bloating, intolerance of fatty foods,
belching, gas, and indigestion.
Symptoms

Above symptoms may be acc/w;

chills,
lowgrade fever,
Syx of obstructive Jaundice {yellowing of
the skin or eyes, and/or clay-colored
stool}.
Gallstone Complications
Gallstone pancreatitis
Acute cholecystitis: 10-20% of pts w/
symptomatic gallstones
GB gangrene

GB perforation

GB empyema (pus in the GB)

Emphysematous cholecystitis (a/w GB

vascular compromise, stones, impaired
immune system, infection w/gas-forming
organisms - clostridium, E. coli, Klebsiella)
Cholecystoenteric fistula
DIAGNOSIS

Based on Hx + P/E
DDX
LabInvx
Imaging
RUQ DDx

Gallbladder:, choledocholithiasis,
cholangitis, cholecystitis.
Hepatitis
Pancreatitis
Labs

Serum amylase/lipase, LFTs.

Stool analysis
Cholidocholithiasis, increased alkaline
phosphatase, conjugated bilirubin, pale
stool.
Acute cholecystitis: Above results +
increased WBC.
Pacreatitis; Raised serum amylase/lipase
Acute hepatitis; raised alanine transferase
{ALT}, mixed type bilirubin, normal stool,
urine urobilinogen.
 Imaging

U/S - gallstone identification false(-) rate

is 5-15%.
It identifies bile duct dilatation w/ 80%
accuracy.
CT scan - used to diagnose
complications
MRI - can detect gallstones and
common duct stones
ERCP - to visualize CBD stones
Ultrasonographic Images of Three
Gallbladders

Strasberg S. N Engl J Med 2008;358:2804-2811

Hepatobiliary Scintigraphy

Strasberg S. N Engl J Med 2008;358:2804-2811

CT Scan of the Abdomen

Thomas L et al. N Engl J Med 1999;341:1134-1138

Treatment
Medical options
Cholesterol gallstones can sometimes be
dissolved by oral ursodeoxycholic acid, but it
may be required that the patient takes this
medication for up to two years.
Gallstones may recur however, once the drug is
stopped.
Obstruction of the common bile duct with
gallstones can sometimes be relieved by
endoscopic retrograde sphincterotomy (ERS)
following endoscopic retrograde
cholangiopancreatography (ERCP).
Treatment
Gallstones can be broken up using a
procedure called lithotripsy (Extracorporeal
Shock Wave Lithotripsy), which is a method of
concentrating ultrasonic shock waves onto the
stones to break them into tiny pieces.
They are then passed safely in the feces.
However, this form of treatment is only suitable
when there are a small number of gallstones.
Treatment

Surgical options
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 gall bladder does not seem
to have any negative consequences in
many people.
Treatment

However, there is a significant portion of

the population between 5 and 40%
who develop a condition called
postcholecystectomy syndrome which
may cause gastrointestinal distress and
persistent pain in the upper right
abdomen.
In addition, as many as 20% of patients
develop chronic diarrhea.
THE END

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