Diagnosis

Cholelithiasis

Etiology

Cause

• Metabolic factors: excess triglycerides --> hepatic secretion --> increased bile cholesterol

• Environmental: diet, weight

• Genetic factors

• Gallstone formation following bariatric surgery/Roux-en-Y: gallbladder emptying slows down

• Bacterial infiltration of the gallbladder is promoted by bile stasis and impaired gallbladder motility

Pathophysiology [oo8]

1. Impaired gallbladder contractility --> reduced emptying --> concentration of excessive cholesterol or bile salts --> crystallized deposits made of cholesterol, bilirubin, and bile

2. 90% are asymptomatic. Only 10% of patients develop symptoms during the first 5 years after diagnosis and 20% by 20 years [fsm]

Complications

• Biliary Colic: migration of a gallstone into the opening of the cystic duct --> incomplete biliary obstruction during gallbladder contraction --> increase in gallbladder wall tension --> self-limiting intermittent, post-prandial epigastric or RUQ pain

• Cholecystitis if prolonged and complete obstruction

• Choledocholithiasis

• Pancreatitis

• Cholecystoenteric fistula

• Gallstone ileus

• Carcinoma of the gallbladder

Risk factors

• Female, Fat, Fertile, Forty, flatulent, Familial, Cystic Fibrosis, sickle cell anemia, pregnancy, oral contraceptives, Western diet, Crohns disease, Ulcerative colitis, hyperlipidemia, ileal resection (due to loss of enterohepatic circulation), and total parenteral nutrition

Epidemiology

Incidence per 100.000 [fsm][fyq]

Approach

• Blood test

• Ultrasound abdomen

• Abdominal x-ray

• CT abdomen

Treatment

1. Symptomatic cholelithiasis --> Laparoscopic cholecystectomy: [fsm][g5z]

2. Asymptomatic cholelithiasis --> Usually no treatment due to risk of complications is higher than the risk of symptomatic disease. Exceptions:

   • Life expectancy > 20 years

   • Calculi > 2 cm in diameter

   • Calculi < 3 mm and patent cystic duct

   • Radiopaque calculi

   • Calcified calculi

   • Polyps in the gallbladder

   • Nonfunctioning gallbladder

   • Calcified gallbladder (“porcelain gallbladder”)

   • Diabetes

   • Severe concomitant chronic disease

   • Women < 60 years (enough life expectancy to develop complications)

   • Individuals living in regions with a high prevalence of gallbladder cancer

3. Nonoperative management:

   • Strict maintenance of a low-fat diet

   • Supportive treatment with antiemetics and pain control

Differential diagnoses

Acute mesenteric ischemia, Acute pancreatitis, Aortic dissection, Appendicitis, Autoimmune hepatitis, Cholangiocarcinoma, Cholecystitis, Choledocholithiasis, Chronic mesenteric ischemia, Esophageal spasm, Gallbladder cancer, Gastroenteritis, Gastroesophageal reflux disease, Myocardial infarction, Pancreatic cancer, Pneumonia, Ulcer disease, Urolithiasis