Gallstones
Prevalence
6% of men and 9% of women
Types
Cholesterol stones (75%)
Black pigment stones (20%)
Brown pigment stones (5%)
Risk Factors
Increasing age
Female sex
Genetic susceptibility
Pregnancy
Diabetes
Dyslipidemia
Obesity
Rapid weight loss
Medications (Fibrates, Ceftriaxone, HRT, COCP)
Prolonged fasting
Chronic Liver Disease
Crohn’s Disease
High bilirubin levels
Protective factors
Vitamin C
PUFA, MUFA and Nuts
Coffee
Physical activity
Statins
Prevention
Three well-balanced meals per day
Regular meal timing
Low in saturated fats
High in fibre
High in calcium
Weight reduction
Regular physical activity
Ursodeoxycholic acid
Symptoms
Biliary colic - intense, dull discomfort, RUQ or epigastrium
Radiate to back or shoulder blade
Associated sweating, nausea, vomiting
Triggered eating especially fatty meal
Sometimes nocturnal pain
Not exacerbated by moving
Typically lasts > 30 minutes, plateau’s within an hour, then starts to subside
Pain occurs by GB contracting in response to hormonal and neural stimulation forcing a stone or sludge against the cystic duct causing an increase in pressure
When GB relaxes, stones/sludge fall back from the cystic duct and pain subsides
Patients are usually not unwell looking with no fever or tachycardia
Attack frequency ranges hours to years, seldom daily
Atypical symptoms include eructation, early satiety, regurgitation, bloating, and chest pain
Complications
Cholecystitis = RUQ pain, fever, ^WCC due to GB inflammation
Choledocholithiasis = Gallstone in common bile duct
Acute cholangitis = Fever, Jaundice and Abdominal pain due to infection + biliary obstruction
Gallstone pancreatitis = Passing stone through tract + acute pancreatitis due to obstruction. can have ^ Bilirubin, ALP, AST, ALT
Blood Tests
Normal in patients with uncomplicated gallstone disease when asymptomic and during attack
Abnormal blood tests suggest a complication
Uncomplicated Gallstones
Normal physical exam
Normal bloods
Ultrasound showing stone or sludge
Differential Diagnosis
Peptic ulcer - Pain limited epigastrium with bloating, fullness, heartburn or nausea
Cholecystitis - RUQ pain, fever, ^ WCC. Well localised pain. U/S confirms.
Choledocholithiasis - Stone in CBD = prolonged severe pain. AST /ALT elevated if stone not passed. Cholestatic pattern with ^ Bilirubin, GGT, ALP. Hypotension. U/S confirms.
Sphincter of Oddi Dysfunction - Biliary colic but abnormal LFT +/- Dilatation of CBD
Functional GB Disorder - Diagnosed of exclusion = Biliary colic with negative imaging.
Natural History
Asymptomatic gallstones - 15 to 25% of patients will become symptomatic after 10 to 15 years of follow up
Risk of complications is 2 to 3% yearly once biliary pain is present from uncomplicated disease
Once a complication, 30% risk per year of another often more severe complication
Pretreatment Imaging
Composition of stone = CT (Non contrast of liver + GB only)
Number + size of stones in GB. = Ultrasound
Patency of cystic duct = Cholecystogram or HIDA
Concentrating ability of GB = Oral Cholecystogram
Non-Surgical Management
Goal of therapy is to reduce symptom severity, clear the gallbladder of stones, and/or decrease risk of complications
Oral bile acid dissolution therapy
Symptomatic patient with biliary colic
Uncomplicated gallstones
Who are unable/unwilling to undergo cholecystectomy
Have small non calcified stones in a functioning gallbladder (<1cm)
10mg/kg daily in two to three divided doses
Monitor with U/S every 6 to 12 months to asses response
Response 30 to 50% for stones up to 20mm
Gallstone recurrent is about 50% at five years
Uncertain benefit
Extracorporeal shock wave lithotripsy
Statins
Ezetimibe
Monoterpenes
Acute Management
NSAIDs
Ketorolac in ED
Surgical Management
Elective cholecystectomy, laparoscopic
Complications including bleeding, abscess, bile leak, biliary injury and bowel injury
5 to 12% develop diarrhoea, mostly in response to large fatty meal, often resolves over months