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Cholelithiasis

Epidemiology

  • Common in Fat, Fertile, Forty, Flatulent, Female
  • Part of Saint’s triad – gallstones, diverticulosis, hiatus hernia

Etiology

Lifestyle

  • Obesity, sedentary lifestyle
  • Diet high in cholesterol

Infections/infestations

  • Bacteria – E. coli, salmonella
  • Parasites – Ascaris lumbricoides

Bile stasis

  • Due to oestrogen therapy, pregnancy, vagotomy

Increased bilirubin production

  • Any causes of hemolysis – hereditary spherocytosis, sickle cell anaemia, thalassemia, malaria, cirrhosis

Types

  • Cholesterol stones – often solitary
  • Mixed stones – most common
  • Pigment stones – contain bilirubin, can be sludge like

Pathogenesis

Cholesterol stones

  • Supersaturation – bile comes supersaturated with cholesterol
    • Normal ratio of bile salts and lecithin to cholesterol is 25:1
    • Ratio <13:1 leads to precipitation of cholesterol
  • Hypomotility/stasis of the bile
  • Nucleation – a glycoprotein in the bile causes formation of cholesterol monohydrate crystals
  • Accretion – hypersecretion of mucous in the gallbladder traps the crystals and causes them to aggregate into stones

Mixed stones

  • Composed of 20-50% cholesterol and other substances (calcium salts of carbonate, phosphate and palmitate; proteins)
  • Often precipitated by infections

Pigment stones

  • Formed due to excess bilirubin in the bile, which combines with calcium to form a solid precipitate
  • Hemolytic anemias are the most common cause

Clinical Features

  • Can be asymptomatic
  • Colicky abdominal pain – in right upper quadrant, radiates to the back and shoulder
    • Accompanied by nausea and vomiting
    • Exacerbated in the supine position e.g. when sleeping
  • Flatulent dyspepsia – abdominal discomfort, belching, heartburn
  • Intolerance of fatty foods

Investigations

  • US abdomen
  • X-ray abdomen
  • Liver function tests
  • WBC count

Treatment

  • Laparoscopic cholecystectomy
    • Calot’s triangle is an important anatomic landmark during laparoscopic cholecystectomy
      • Significance – allows surgeon to correctly identify and safely ligate the cystic duct and cystic artery
      • Borders – inferior surface of liver, common hepatic duct, cystic duct
      • Contents – right hepatic artery, cystic artery, lymph node of Lund
  • Open cholecystectomy – in suspected common bile duct stones; Mirizzi syndrome; suspected gallbladder carcinoma
  • Dissolution using ursodeoxycholic acid – for asymptomatic cholesterol stones

Complications

In the gallbladder

  • Acute or chronic cholecystitis
  • Empyema gallbladder
  • Perforation – leading to biliary peritonitis
  • Carcinoma gallbladder

In the common bile duct

  • Secondary CBD stones
  • Cholangitis
  • Pancreatitis
  • Mirizzi syndrome (see below)

In the intestine

  • Cholecystoduodenal fistula – leads to gallstone ileus (intestinal obstruction

Mirizzi syndrome

  • Extrinsic compression of an extrahepatic biliary duct from one or more calculi within the cystic duct or gallbladder
  • Patients can present with recurrent episodes of jaundice and cholangitis
Classification  
  • Type I – extrinsic compression of the common hepatic duct (CHD)
  • Type II – erosion of CHD wall and formation of cholecystocholedochal fistula (up to one-third CHD wall circumference is involved)
  • Type III – up to two-thirds of CHD wall circumference is involved in a cholecystocholedochal fistula
  • Type IV – entire CHD wall is involved in a cholecystocholedochal fistula
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