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General Considerations

Approximately 10%-20% of the population have gallstones, making biliary pathology an increasing consideration in a patient with abdominal pain. Females are twice as likely to have gallstones. Gallstones are more frequently seen with increasing age, in the obese, and are more common in Caucasians and native Americans than African Americans. Most with cholelithiasis remain asymptomatic and never require surgery, but the sequelae of biliary disease remain significant: symptomatic cholelithiasis, gallstone pancreatitis, acute cholecystitis, chronic cholecystitis, choledocholithiasis, and ascending cholangitis. Understanding the basic pathophysiology of each of these conditions is an essential to appropriately diagnose and treat these conditions.

A basic understanding of biliary disease requires a vocabulary of terms used in describing them. Many have similar sounding names and can be confusing. A summary of the definitions can be found in Table 32-1. Although, the treatment of most biliary diseases ultimately requires cholecystectomy, each condition must be evaluated and treated in a unique fashion.

Table 32-1. Basic Definitions.


Asymptomatic Cholelithiasis

A landmark study from the University of Michigan followed the course of 123 faculty members identified as having asymptomatic gallstones during a routine health examination. After over two decades of follow-up, 14 (11%) patients went on to develop complications requiring surgery. Subsequent studies have not demonstrated a survival advantage with prophylactic cholecystectomy. As a result of these studies, prophylactic cholecystectomy for asymptomatic cholelithiasis is generally not indicated.

Symptomatic Cholelithiasis

Essentials of Diagnosis

  • Episodic RUQ pain.
  • Ultrasound evidence of gallstones.

Unlike asymptomatic cholelithiasis, symptomatic cholelithiasis will generally necessitate operative intervention. The typical patient presentation will include right upper quadrant abdominal pain, usually following a fatty meal and frequently associated with nausea (biliary colic). The pain can be severe and debilitating, and a trip to the emergency room is not an infrequent occurence. Symptoms are related to transient obstruction of the gallbladder neck or infundibulum by stones or biliary sludge. As the gallbladder attempts to contract in response to cholecystokinin, the obstructed cystic duct prevents the egress of bile from the gallbladder into the biliary system, resulting in acute right upper quadrant pain. In addition to right upper quadrant pain, the character of biliary colic is often described as a colicky or crampy pain which may radiate to the back or shoulder. The pain is generally postprandial in nature and ...

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