Review Note

Last Update: 10/31/2024 11:05 AM

Current Deck: State Exam::Gastroenterology

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Cholelithiasis – risk factors, clinical features, diagnostics, complications, treatment principles, complications

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Cholelithiasis

Definition: Formation of gallstones in the gallbladder, primarily composed of cholesterol (up to 95%), with others being pigment stones or mixed stones.
Risk Factors:
- Cholesterol stones:
  - Obesity, insulin resistance, dyslipidemia.
  - Female sex (due to hormonal effects):
    - Estrogen increases cholesterol-rich bile secretion.
    - Progesterone decreases gallbladder contraction, leading to bile stasis.
  - Pregnancy (due to increased estrogen and progesterone).
  - Age >40.
  - Family history of cholesterol stones.
  - Certain drugs (e.g., fibrates, estrogen therapy, contraceptives).
  - Malabsorption conditions (e.g., Crohn’s disease, ileal resection, cystic fibrosis).
  - Rapid weight loss.
- Black pigment stones (<10%):
  - Chronic hemolytic anemias (e.g., sickle cell disease, hereditary spherocytosis).
  - Liver cirrhosis.
  - Crohn’s disease.
  - Total parenteral nutrition.
  - Advanced age.
- Mixed stones (<10%):
  - Bacterial infections or parasites in the biliary tract.
  - Primary sclerosing cholangitis (PSC).
Clinical Features:
- Most patients are asymptomatic (gallstones are often an incidental finding).
- ROME IV criteria for biliary pain (all criteria must be met):
  - Pain in the epigastrium and/or right upper quadrant (RUQ).
  - Pain episodes last ≥30 minutes.
  - Recurrent symptoms, not daily.
  - Pain builds to a steady level.
  - Pain is severe, disrupting daily activities or leading to emergency visits.
  - Pain is not significantly related to bowel movements or relieved by posture or acid suppression.
  - Supportive criteria: Pain with nausea/vomiting, radiates to the back or right infrascapular region, can awaken from sleep.
- Common triggers: Fatty meals, but some patients may experience night pain without a clear trigger.
Diagnostics:
- Laboratory Tests:
  - Normal lab values are typical in uncomplicated cases.
  - Abnormal values (leukocytosis, elevated ALAT, ASAT, ALP, amylase, lipase, or bilirubin) indicate possible complications.
- Imaging:
  - 1st line: Abdominal ultrasound (US) to detect hyperechogenic foci with acoustic shadowing.
  - 2nd line: Magnetic resonance cholangiopancreatography (MRCP).
  - Others: CT scan (less sensitive), abdominal x-ray, endoscopic ultrasound (EUS).
Treatment Principles:
- Supportive Care:
  - Analgesia: NSAIDs or opioids for severe pain.
  - Spasmolytics alongside analgesics in severe pain.
  - Lifestyle changes: Avoid fatty foods, regular physical activity, avoid lithogenic drugs (e.g., estrogen, fibrates).
- Elective Laparoscopic Cholecystectomy:
  - Indications:
    - Symptomatic cholelithiasis (uncomplicated and complicated).
    - Asymptomatic patients with:
      - High risk of complications (e.g., immunocompromised, multiple gallstones).
      - High cancer risk (e.g., gallbladder polyps, porcelain gallbladder, large stones >3 cm).
      - High likelihood of symptoms (e.g., hemolytic anemia).
  - Contraindications:
    - No absolute contraindications.
    - Relative contraindications include hemodynamic or respiratory instability, cirrhosis, coagulation issues, portal hypertension, or morbid obesity.
- Managing Choledocholithiasis:
  - Removal of stones in the common bile duct via ERCP or surgery, followed by cholecystectomy.
- Non-Surgical Options (for those unable or unwilling to undergo surgery):
  - Lifestyle modifications (as mentioned).
  - Oral bile acid dissolution therapy with Ursodeoxycholic acid (6–24 months) for small cholesterol stones (3–6 mm).
  - Extracorporeal shock wave lithotripsy (rarely used).
Complications:
- Acute or chronic cholecystitis.
- Biliary pancreatitis.
- Choledocholithiasis (with or without acute cholangitis).
- Gallbladder cancer.

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Gastroenterology

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