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Gallstone

From: cavila Boac marinduque
Gallstone
Classification and external resources

Numerous small gallstones, composed largely of cholesterol
ICD-10 K80.
ICD-9 574
OMIM 600803
DiseasesDB 2533
MedlinePlus 000273
eMedicine emerg/97
MeSH D042882
A gallstone is a crystalline concretion formed within the gallbladder by accretion of bile components. These calculi are formed in the gallbladder, but may pass distally into other parts of the biliary tract such as the cystic duct, common bile duct, pancreatic duct, or the ampulla of Vater.

Presence of gallstones in the gallbladder may lead to acute cholecystitis, an inflammatory condition characterized by retention of bile in the gallbladder and often secondary infection by intestinal microorganisms, predominantly Escherichia coli and Bacteroides species. Presence of gallstones in other parts of the biliary tract can cause obstruction of the bile ducts, which can lead to serious conditions such as ascending cholangitis or pancreatitis. Either of these two conditions can be life-threatening, and are therefore considered to be medical emergencies.


Definitions

Presence of stones in the gallbladder is referred to as cholelithiasis (from the Greek: chol-, "bile" + lith-, "stone" + iasis-, "process"). 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"). Choledocholithiasis is frequently associated with obstruction of the biliary tree, which in turn can lead to acute ascending cholangitis (from the Greek: chol-, "bile + ang-, "vessel" + itis-, "inflammation"), a serious infection of the bile ducts. Gallstones within the ampulla of Vater can obstruct the exocrine system of the pancreas, which in turn can result in pancreatitis.

Characteristics and composition



Gallbladder opened to show numerous gallstones. The large, yellowish calculus is probably composed largely of cholesterol, while the greenish to brownish color of the other stones suggests these are composed of bile pigments such as biliverdin and stercobilin.



Images of a CT of gallstones
Gallstones can vary in size from as small as a grain of sand to as large as a golf ball. [1] 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.[citation needed] The composition of gallstones is affected by age, diet and ethnicity.[2] 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).[3]

Pigment stones
Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese classification system).[3]

Mixed stones
Mixed gallstones typically contain 20–80% cholesterol (or 30–70%, according to the Japanese classification system).[3] Other common constituents are calcium carbonate, palmitate phosphate, bilirubin, and other bile pigments. Because of their calcium content, they are often radiographically visible.


Gallbladder opened to show numerous small cholesterol gallstones]]


µCT of a gallstone. Image acquisition done using "CT Alpha" by "Procon X-Ray GmbH", Garbsen, Germany. Visualization done with "VG Studio Max 2.0" by "Volume Graphics", Heidelberg, Germany

Cholelithiasis

Signs and symptoms
Gallstones may be asymptomatic, even for years. These gallstones are called "silent stones" and do not require treatment.[4][5] Symptoms commonly begin to appear once the stones reach a certain size (>8 mm).[6] A characteristic symptom of gallstones is a "gallstone attack", in which a person may experience intense pain in the upper-right side of the abdomen, often accompanied by nausea and vomiting, that steadily increases for approximately 30 minutes to several hours. A patient may also experience referred pain between the shoulder blades or below the right shoulder. These symptoms may resemble those 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.

A positive Murphy's sign is a common finding on physical examination.

Causes
Gallstone risk factors include overweight, age near or above 40, female, and pre-menopausal;[7] the condition is more prevalent in caucasians than in people of other races. A lack of melatonin could significantly contribute to gallbladder stones, as melatonin both inhibits cholesterol secretion from the gallbladder, enhances the conversion of cholesterol to bile, and is an antioxidant, capable of reducing oxidative stress to the gallbladder.[8] Researchers believe that gallstones may be caused by a combination of factors, including inherited body chemistry, body weight, gallbladder motility (movement), and perhaps diet. The absence of such risk factors does not, however, preclude the formation of gallstones.

No clear relationship has been proven between diet and gallstone formation; however, low-fiber, high-cholesterol diets and diets high in starchy foods have been suggested as contributing to gallstone formation. Other nutritional factors that may increase risk of gallstones include rapid weight loss, constipation, eating fewer meals per day, eating less fish, and low intakes of the nutrients folate, magnesium, calcium, and vitamin C.[9] On the other hand, wine and whole-grain bread may decrease the risk of gallstones.[10] Pigment gallstones are most commonly seen in the developing world. Risk factors for pigment stones include hemolytic anemias (such as sickle-cell disease and hereditary spherocytosis), cirrhosis, and biliary tract infections.[11] People with erythropoietic protoporphyria (EPP) are at increased risk to develop gallstones.[12][13]

[edit] Pathophysiology
Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high concentration of cholesterol, two other factors are important in causing gallstones. 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. 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.

Diagnosis


A 1.9 cm gallstone impacted in the neck of the gallbladder and leading to cholecystitis as seen on ultrasound. Note the 4 mm gall bladder wall thickening.


Gallstones as seen on plain Xray.
[edit] Treatment
Medical
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.[14] 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). Gallstones can be broken up using a procedure called extracorporeal shock wave lithotripsy (often simply called "lithotripsy"),[14] 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 suitable only when there is a small number of gallstones.

Surgical
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[15] which may cause gastrointestinal distress and persistent pain in the upper-right abdomen, as well as a 10% chance of developing chronic diarrhea.[16]

There are two surgical options for cholecystectomy:

Open cholecystectomy: This procedure is performed via an incision into the abdomen () 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.laparotomy[4]
Laparoscopic cholecystectomy: This procedure, introduced in the 1980s,[17] 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.[4] 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.[citation needed]
Choledocholithiasis



MRCP image of two stones in the distal common bile duct
Choledocholithiasis is the presence of gallstones in the common bile duct. This condition causes jaundice and liver cell damage, and requires treatment by cholecystectomy and/or ERCP.

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.[4] 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.

[edit] 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


Fluoroscopic image taken during ERCP and duodenoscope assisted cholangiopancreatoscopy (DACP). Multiple gallstones are present in the gallbladder and cystic duct. The common bile duct and pancreatic duct appear to be patent.
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.[18]

In other animals

Gallstones are a valuable by-product of meat processing, fetching up to US$10–per–gram in their use as a purported antipyretic and antidote in the folk remedies of some cultures, in particular, in China. The finest gallstones tend to be sourced from old dairy cows, which are called (yellow thing of oxen) in Chinese. Those obtained from dogs, called Gou-Bao (treasure of dogs) in Chinese, are also used today. Much as in the manner of diamond mines, slaughterhouses carefully scrutinize offal department workers for gallstone theft.

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Gallstones: complications



Most people with gallstones never have a serious complication. However, if the gallstones are not treated, they can cause jaundice (a yellow discolouration of the skin and whites of the eyes), pancreatitis or infections in the gallbladder or bile duct in some people.

Some of the complications relating to gallstones include inflammation of the gallbladder (cholecystitis), inflammation of the bile duct (cholangitis), inflammation of the pancreas (biliary pancreatitis), and obstruction of the intestine (gallstone ileus).

Acute cholecystitis (sudden inflammation of the gallbladder)

Acute cholecystitis (inflammation of the gallbladder) is a condition indicated by a sudden attack of pain in the upper abdomen that lasts more than 12 hours. It may be triggered by a large meal or a meal with fatty foods. Nausea and vomiting may also occur. It is often accompanied by a high fever. If you have this condition you are likely to be hospitalised and treated with quick-acting formulations of pain relievers, usually by injection. The inflammation is not always due to infection, but if secondary infection is present, you may also be prescribed a broad-spectrum antibiotic. Fluids are usually given intravenously, and your stomach kept empty by suctioning to reduce stimulation of your gallbladder, until the inflammation has subsided.

Acute cholecystitis is distinguished from biliary colic, which is the pain caused when gallstones obstruct the gallbladder but no inflammation is present. This pain tends to be less sharp, there is no fever, and the abdomen is less exquisitely tender.

It is usual for the gallbladder to be removed once your condition has stabilised, in order to avoid further pain and complications, and to reduce the chance of readmission.

Chronic cholecystitis

Repeated attacks of acute cholecystitis can damage the gallbladder and result in chronic cholecystitis (long-lasting gallbladder inflammation). Chronic cholecystitis is more common in women. Symptoms include episodes of upper abdominal pain, often accompanied by nausea or vomiting. Belching and bloating are common, and the symptoms may be brought on by fatty or large meals.

While avoiding fatty foods may reduce the frequency of episodes, surgery to remove the gallbladder is usually required to treat chronic cholecystitis.

Acute cholangitis

Cholangitis (inflammation of the bile ducts) may occur if your bile ducts become blocked and subsequently infected with bacteria from the small intestine. This is a serious condition requiring urgent treatment. If not treated with antibiotics and a procedure to unblock the ducts, fever, abdominal pain and jaundice will develop and death can result. The bile ducts may be unblocked by the insertion of a tube (stenting) or through surgical drainage.

Acute biliary pancreatitis

Pancreatitis (inflammation of the pancreas) is a potentially serious disorder that occasionally develops in people with gallstones. It is more common in people with numerous small stones, and occurs when gallstones passing through the common bile duct temporarily obstruct the duct leading from the pancreas (pancreatic duct). The pancreas is an organ that produces digestive enzymes and hormones such as insulin. This complication requires urgent hospitalisation, and is treated with techniques known as endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. The techniques involve visualising any blockages with dye and then making a cut to release any stones causing the blockage.

Gallstone ileus

Gallstone ileus is a condition where gallstones obstruct the small or large intestine. Gallstone ileus can happen when an inflamed gallbladder becomes stuck to the intestine, and the gallstones erode their way through the gallbladder wall and into the intestine where they cause a blockage. The treatment for this is urgent surgery.

Obstructive jaundice or cholestasis

Obstructive jaundice is jaundice resulting from bile not being able to flow, causing yellowing of the skin and eyes due to build up of bile pigments (bilirubin). The bile ducts may be blocked by a stone, a tumour or a narrowing (stricture).

Cholestasis is the word doctors use for a reduction in flow or stoppage in the flow of bile. Because the bile cannot flow freely, it backs up in the bloodstream. The urine may become dark because the kidneys try to pass the extra bilirubin, while the faeces may become pale because they have no bilirubin to give them colour.

Your doctor may suggest you have an ultrasound scan so that they can see whether there are stones blocking the ducts or if there is a tumour causing the blockage. If you have stones blocking bile ducts, surgery will normally be required to unblock the ducts. This may be via endoscopy.

Narrowing of the bile duct (a stricture) may happen after surgery has been carried out to remove the gallbladder (a cholecystectomy). It will usually be treated by inserting a stent to push back the narrowed walls of the duct.

Tumours that block the bile duct include cancers of the pancreas or gallbladder.

Gallbladder cancer

Having gallstones can increase the risk of developing gallbladder cancer, but this type of cancer is rare — most people with gallstones never develop gallbladder cancer.

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