Cholelithiasis

• • Divided into symptomatic and asymptomatic

  • Caused by cholesterol (most common), black pigment, or brown pigment stones

  • Cholesterol stones form in 20% of women and 10% of men by age 60

  • Cholesterol stone risk factors include:

  • -Female gender

    -Age

    -Obesity

    -Estrogen exposure

    -Fatty diet

    -Rapid weight loss

  • Black pigment stone risk factors include:

  • -Hemolytic disorders

    -Living in Asia

  • Brown pigment stone risk factors include:

  • -Biliary stasis

    -Biliary infections

Epidemiology

• • 20 million affected in United States

  • Symptoms develop in about 3% of asymptomatic patients each year (20-30% over 20 years)

  • Each year, complicated gallstone disease affects 3-5% of patients who are symptomatic

  • Each year, complicated gallstone disease affects < .5% of patients who are asymptomatic

Symptoms and Signs

• • Asymptomatic

  • Biliary colic

  • -Right upper quadrant or epigastric

    -Episodic, often after meals or at night, lasting as long as 2-4 hours

  • Nausea

  • Vomiting

  • Diarrhea

  • Mild right upper quadrant tenderness to palpation

Laboratory Findings

• • Normal liver function tests, normal amylase and lipase, normal WBC count

Imaging Findings

• • Right upper quadrant US showing acoustically dense stones in gallbladder with acoustic shadowing without evidence of gallbladder wall thickening or pericholecystic fluid (> 90% sensitive for gallstones)

• • Other causes of abdominal pain

Rule Out

• • Cholecystitis

  • Choledocholithiasis

  • Pancreatitis

• • History and physical exam

  • CBC

  • Liver function tests

  • Amylase and lipase

  • Right upper quadrant US

Surgery

• • Laparoscopic cholecystectomy

  • Open cholecystectomy

Indications

• • Symptomatic cholelithiasis

  • Porcelain gallbladder (25% risk of carcinoma)

Contraindications

• • First or third trimester of pregnancy (relative)

  • Previous upper abdominal surgeries (laparoscopic)

Complications

• • Bile duct injury or leak

References