Skip to Main Content

CHOLELITHIASIS

There are two major types of gallstones: cholesterol and pigment stones. Cholesterol gallstones contain >50% cholesterol monohydrate. Pigment stones have <20% cholesterol and are composed primarily of calcium bilirubinate. In the United States, 80% of stones are cholesterol and 20% are pigment.

EPIDEMIOLOGY

One million new cases of cholelithiasis per year in the United States. Predisposing factors include demographic/genetics (increased prevalence in North American Indians), obesity, weight loss, female sex hormones, age, ileal disease, pregnancy, type IV hyperlipidemia, and cirrhosis.

SYMPTOMS AND SIGNS

Many gallstones are "silent," i.e., present in asymptomatic pts. Symptoms occur when stones trigger inflammation or cause obstruction of the cystic or common bile ducts. Major symptoms: (1) biliary colic—a severe steady ache in the RUQ or epigastrium that begins suddenly; often occurs 30–90 min after meals, lasts for several hours, and occasionally radiates to the right scapula or back; (2) nausea, vomiting. Physical exam may be normal or show epigastric or RUQ tenderness.

LABORATORY

Occasionally, mild and transient elevations in bilirubin [<85 μmol/L (<5 mg/dL)] accompany biliary colic.

IMAGING

Only 10% of cholesterol gallstones are radiopaque. Ultrasonography is best diagnostic test. The oral cholecystogram has been largely replaced by ultrasound, but may be used to assess the patency of the cystic duct and gallbladder emptying function (Table 161-1).

TABLE 161-1DIAGNOSTIC EVALUATION OF THE BILE DUCTS

DIFFERENTIAL DIAGNOSIS

Includes peptic ulcer disease (PUD), gastroesophageal reflux, irritable bowel syndrome, and hepatitis.

COMPLICATIONS

Cholecystitis, pancreatitis, cholangitis.

TREATMENT Cholelithiasis

In asymptomatic pts, risk of developing complications requiring surgery is small. Elective cholecystectomy should be reserved for: (1) symptomaticpts (i.e., biliary colic despite low-fat diet); ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.