CHOLELITHIASIS

Name : Rianti
NIM : 20130310092
NIPP : 20174011078
Definition

■ Cholelithiasis/gallstones are solid particles that develop in the gallbladder, formed

by precipitation of supersaturated bile . This stone may occur in the gallbladder or
the biliary tract
■ Cholelithiasis (calculi or gallstones) usually form in the gallbladder from the solid
constituents of bile and vary greatly in size, shape and composition.
ANATOMY OF GALL BLADDER
■ A pear-shaped, hollow, saclike organ, 7.5 to 10 cm (3-4
inch) long, lies in a shallow depression on the inferior
surface of the liver, to which it is attached by loose
connective tissue.
• The capacity of the gallbladder is 30 to 50 ml of bile.
• Its wall is composed largely of smooth muscle.
• The gallbladder is connected to the common bile duct by
the cystic duct
epidemiology

■ More common in women. Etiology may be secondary to variations in estrogen

causing increased cholesterol secretion, and progesterone causing bile stasis.
■ Pregnant women more likely to have symptoms.
■ Women with multiple pregnancies at higher risk
■ Oral contraceptives, estrogen replacement tx.
■ It is uncommon for children to have gallstones. If they do, its more likely that they
have congenital anomalies, biliary anomalies, or hemolytic pigment stones.
■ Incidence of GS increases with age 1-3% per year.
Risk Factor
■ Older age
■ Female
■ Obesity
■ Rapid Weight loss
■ Pregnancy
■ Disease of terminal ileum
■ Hipertrigliseridemia
■ Oral contraception
■ Diet
■ Genetic
■ Metabolic syndrome
Pathophysiology
■ Formation of each types is caused by crystallization of bile.
■ Cholesterol stones most common. cholesterol stones are
formed by an imbalance between pronucleation factor (bile
cholesterol and mucus glycoprotein) with antinucleation or
inhibiting factors (bile salts and lecithin)
 PATHOPHYSIOLOGY
Decreased bile acid synthesis

Increased cholesterol synthesis in the liver

Increased Super saturation of bile with cholesterol

Formation of precipitates

Gall stones (Cholelithiasis)

 TYPES OF GALLSTONES
■ Cholesterol stones
■ Pigment stones
■ Mixed stones - the most common type. They are comprised of cholesterol and salts.
■ Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol.
■ Pigment stones are small, dark stones made of bilirubin. The exact cause is not known. They
tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood
disorders such as sickle cell anaemia in which too much bilirubin is formed.
Clinical manifestation
■ Gallstones cause symptoms by obstruction of the cystic duct, common in bile duct, or
erosion into neighboring organs.
■ ,3 clinical stages: asymptomatic, symptomatic, and with complications (cholecystitis,
cholangitis, CBD stones).
■ Most (60-80%) are asymptomatic
■ Biliary colic : describe as epigastric pain , righ upper quadrant abdomen, with radiation
to shoulder/scapular may suggest it. The pain is steady rather than intermittent and
lasts 1-6 hours, the pain caused by brief impaction of the gallstones In the neck of the
gallbladder
■ Most patients develop symptoms before complications.
■ Feeling of Fullness
■ Abdominal distention
■ Distress may follow a meal high in fried or fatty foods
■ Fever
■ Jaundice
■ Yellow colour skin and mucous membrane
■ Changes in urine and stool colour (Grayish, like putty, and usually described as “clay-
colored” stool.)
■ Vital signs and physical findings in asymptomatic cholelithiasis are completely normal.
■ Fever, tachycardia, hypotension, alert you to more serious infections, including cholangitis,
cholecystitis.
■ Murphy’s sign (+)
examination

■ Labs with asymptomatic cholelithiasis and biliary colic should all be normal.
■ WBC, elevated LFTS may be helpful in diagnosis of acute cholecystitis, but normal values
do not rule it out.
■ Study by Singer et al examined utility of labs with chole diagnosed with HIDA, and
showed no difference in WBC, AST,ALT Bili, and Alk Phos, in patients diagnosed and
those without.
■ Elevated WBC is expected but not reliable.
■ In retrospective study, only 60% of patients with cholecytitis had a WBC greater than
11,000. A WBC greater than 15,000 may indicate perforation or gangrene.
■ ALT, AST, AP more suggestive of CBD stones
■ Amylase elevation may be GS pancreatitis.
Differential diagnosis
■ Appendicitis
■ Cholangitis
■ Cholesistitis
■ choledocolithiasis
■ Diverticulitis
■ Gastroenteritis, hepatitis
■ Pancreatitis, renal colic, pneumonia
 DIAGNOSTIC EVALUATION

■ Laboratory tests
■ Abdominal X-ray
■ USG
■ Radionuclide imaging or cholecintography
■ Cholecystography
■ Endoscopic retrograde cholangiopancreatography (ERCP)
■ Percutaneous transhepatic cholangiography (PTC)
 NONSURGICAL REMOVAL
■ Asymptomatic cholelithiasis : sports, diet low
cholesterol
■ Oral dissolution therapy. Ursodiol and
chenodial
■ Dissolving gallstones – MTBE – Methyl tertiary
butyl ether
■ Extracorporeal shock-wave lithotripsy (ESWL)
■ Intracorporeal lithotripsy
 SURGICAL MANAGEMENT

■Cholecystectomy
■Minicholecystectomy
■Laparoscopic cholecystectomy
■Percutaneous cholecystostomy
complication

■ Cholangitis, sepsis
■ Pancreatitis
■ Perforation (10%)
■ GS ileus (mortality 20% as diagnosis difficult).
■ Hepatitis
■ Choledocholithiasis
prognosis

■ Uncomplicated cholecystitis as a low mortality.

■ Emphysematous GB mortality is 15%
■ Perforation of GB occurs in 3-15% with up to 60% mortality.
■ Gangrenous GB 25% mortality.