4th year pathology

1. Cholelithiasis
Presentation by Dr. Hassan Yar
Pathology Dept. GMC

2. Outlines
• Understanding gallstones and it’s types
• Pathophysiology and morphology
• Clinical features
• Diagnosis
• Complications

3. Introduction to gallstones
• Gallstones refer to concretions made in gallbladder out of bile
components.
• The term Cholelithiasis may refer to presence of gallstones or disease
caused by it.
• It is one of the leading cause of general and Hepatobiliary surgeries.

4. Bile physiology
• Bile is a greenish yellow aqueous solution produced and secreted by
the liver.
• Bile flows into the gallbladder (from liver via hepatic ducts), where it
is concentrated and stored.
• The hormone cholecystokinin (CCK), regulates it’s flow/secretion.
• Bile acids represent the primary pathway for cholesterol catabolism.
• Two main functions:
1. Excretion of hepatic metabolites
2. Emulsification of fat

5. Components of bile
1. Bile salts/acids (67%), potent “digestive surfactants”
2. Phospholipids (22%)
3. Proteins (4.5%), free CH (4%), conjugated bilirubin (0.3%)
4. Water, electrolytes, bicarbonates

8. Types of gallstones
• There are two main types of gallstones:
1. Cholesterol gallstones
2. Pigment gallstones
A minor subset of Mixed gallstones is also present.

9. Cholesterol stones
• 75% of the cases
• Primarily in lumen
• Contains CH(50-100%), calcium carbonate, phosphate and bilirubin
• Radiolucent If calcium carbonate is not present in sufficient amount

10. Pigment stones
Black pigment stones
• Sign of chronic EHA
• Calcium + UCB = calcium
bilirubinate (black)
• Radiopaque
Brown pigment stones
• Sign of infection in the CBD
• Asians
• Soapy fatty acid residue
• Radiolucent

11. Morphology
CH stones
• Pale yellow to gray or black
• Obvious and firm
• Faceted/rough
Pigment stones
Black Stones:
• Small, fragile, numerous
Brown Stones:
• Single or few
• Soft, greasy and soaplike

15. Pathogenesis
There are 3 main concepts:
1. Supersaturation (of bile with CH): either by ⬆️CH or ⬇️bile salts/acids
and lecithin
2. ⬆️ Bilirubin: esp. in hemolytic anemia or infections, causing UCB to
form precipitates with bile pigments
3. Stasis coupled with ⬆️ mucin secretion

17. Risk factors

18. Risk factors
Predisposing factors for cholesterol stones include conditions which
imbalances equilibrium of cholesterol metabolism e.g. age, gender
• females >40yrs
• OCPs
• Obesity
• Rapid weight loss
On the other hand, pigment stones form due to presence of
unconjugated bilirubin e.g.
• Hemolytic anemias
• Infections
• Cirrhosis
• Pathologies of biliary tree

19. Clinical features
• Mostly asymptomatic (depends on the causative pathology)
• Spasmodic pain RUQ/Epigastrium
• Fever
• Jaundice
• Nausea/Vomiting
• Bloating
• Indigestion

20. Diagnosis
Lab investigations are aimed at diagnosing the underlying pathology
and includes:
• CBC
• LFTs
• Amylase/Lipase
The definitive diagnosis of gallstones is usually reached by
ultrasonography and others include a mix radiological and endoscopic
procedures.
• ERCP (endoscopic retrograde cholangiopancreatography)
• MRCP (magnetic resonance cholangiopancreatography)
• PTC (percutaneous transhepatic cholangiography)

21. Complications
• Cholecystitis
• Gallbladder empyema
• Obstruction of biliary/pancreatic ducts
• Perforation due to long standing obstruction
• Gallstone ileus (intestinal obstruction)
• Adenocarcinoma of gall bladder

22. Treatment/Prevention
Life style changes: Preventing cholelithiasis
• Regular exercise
• Coffee consumption
• Avoiding lithogenic diet
• Maintain a healthy weight
Medical management: mostly in asymptomatic cases
• Ursodeoxycholic acid (xray –ve stones)
• Extracorporeal shockwave lithotripsy (particularly for noncalcified cholesterol gallstones)
Surgical management: symptomatic cases
• Cholecystectomy (open or laproscopic)