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  • • Cholesterol stone risk factors include:

    • -Female gender

      -Age

      -Obesity

      -Estrogen exposure

      -Fatty diet

      -Rapid weight loss

    • Complicated gallstone disease affects < 0.5% annually of patients who are asymptomatic

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Epidemiology

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  • • Average age generally 10 years older than those affected by cholelithiasis (eg, 40-50 years of age)

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Symptoms and Signs

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  • • Right upper quadrant pain

    • Painless jaundice

    • Both pain and jaundice

    • Fever

    • Asymptomatic

    • Nausea

    • Vomiting

    • Anorexia

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Laboratory Findings

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  • • Conjugated hyperbilirubinemia (for choledocholithiasis)

    • Elevated alkaline phosphatase (for choledocholithiasis)

    • Leukocytosis (for pancreatitis or cholangitis)

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Imaging Findings

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  • • Right upper quadrant US showing presence of gallstones, dilated common bile duct (CBD) (> 6 mm) and CBD stone in only 20-30% of patients with choledocholithiasis

    • ERCP showing dilated CBD and presence of single or multiple CBD stones in patients with choledocholithiasis

    • ERCP showing impacted ampullary gallstone in < 10 % of patients with gallstone pancreatitis

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  • • Presence of signs or symptoms suggestive of cholangitis

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Rule Out

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  • • Biliary stricture

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  • • History and physical exam

    • CBC

    • Liver function tests

    • Amylase and lipase

    • Right upper quadrant US

    • ERCP or laparoscopic cholangiogram

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Surgery

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  • • ERCP with sphincterotomy and stone extraction followed by laparoscopic cholecystectomy (preferred when cholangitis present or if pancreatitis does not resolve)

    • Laparoscopic cholecystectomy with CBD exploration

    • Laparoscopic cholecystectomy and cholangiogram followed by ERCP and stone extraction (preferred stone extraction technique is center specific for stones noted on screening cholangiogram following resolution of gallstone pancreatitis)

    • Percutaneous transhepatic cholangiography and stone extraction if ERCP unsuccessful and cholangitis present

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Indications

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  • • Choledocholithiasis noted to be symptomatic or asymptomatic

    • Gallstone pancreatitis

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Medications

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  • • Antibiotics to cover GI flora for cases of cholangitis

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Complications

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  • • Pancreatitis (for ERCP)

    • Bile duct injury or leak

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Prognosis

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  • • Gallstone pancreatitis resolves in > 90% of cases

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Prevention

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  • • Treatment of symptomatic cholelithiasis

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References

Binmoeller KF, Schafer TW. Endoscopic management of bile duct stones. J Clin Gastroenterol. 2001;32:106.  [PubMed: 11205644]
Beckingham IJ: ABC of diseases of liver, pancreas, and biliary system. Gallstone disease. BMJ 2001;322:91.  [PubMed: 11154626]

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