General overview about gall stones, types, clinical features, diagnosis and treatment perspectives

1. Cholelithiasis
Suman Raj Baral

2. Incidence
• In USA or Europe, 80% are cholesterol or mixed stones
• Cholesterol or mixed stones contain 51-99 % pure cholesterol plus
admixture of calcium salts, bile acids, bile pigments and phospholipids
• Pigment stones contain less than 30% cholesterol

3. Pigment
Stones
Brown
Contains calicium bilirubinate , palmitate
or stearate as well as cholesterol
Rare in Gall bladder
Formed in Bile Duct
Related to bile stasis and infection:
Gram Negative bacteria(E.coli and
Klebsiella) secretes beta-glucuronidase
which deconjugates the soluble
conjugated bilirubin
Free indirect bilirubin precipitates and
combines with cacium and bile to form
brown stones
Black
Black stones are composed of insoluble bilirubin
pigment polymer mixed with calcium
phosphate and calcium bilirubinate
Predisposing factors:
Hemolytic Disorders, Mechanical Prosthetic valves,
Cirrhosis, Gilbert’s Syndrome, Cystic Fibrosis, Ileal
disease or resection

4. Factors forming Gall Stones
Lithogenic Bile :
• Increased biliary cholesterol: Obesity, Cholesterol rich diet, Clofibrate therapy
• Decreased Bile acids: Primary Biliary Cirrhosis, Impaired EHC of bile acids-
Ileal resection , cholestyramine therapy or colestipol(bile acid sequestrants)
• Decreased biliary lecithin- MDR-3 gene mutation leads to defective lecithin
secretion in bile
Nucleation :
Pronucleating Vs Anti-nucleating factors- excess pronucleation(mucin,
non mucin glycoprotein,Infection) or defective anti nucleation (Apo A-I and
A-II)

5. Risk Factors
• Obesity
• Rapid weight loss
• First degree relatives
• Childbearing
• Multiparity
• Female Sex
• Drugs- Ceftriaxone, TPN, post menopausal estrogens
• Ileal disease, resection or bypass
• Increasing age

6. Pathogenesis
• Cholesterol is insoluble in water ( water is a major constituent of bile-
85-95%
• Bile acid and phospholipids in bile keep cholesterol in solution by the
formation of micelles
• An excess of cholesterol relative to bile acids and phospholipids
allows cholesterol to form crystals and such bile is called lithogenic or
super saturated bile.

7. Clinical Features
• Silent Stones(Asymptomatic)
• Symptomatic Cholelithiasis ( Biliary Colic)
• Features of Acute Calculus Cholecystitis
• Pain at right hypochondrium, radiating to tip of right shoulder
• Vomiting
• Murphy’s Sign positive

8. Investigations
• Oral Cholecystography ( Graham Cole test)
• Oral administration of a radiopaque compound that is absorbed, excreted by
the liver and passed into the gall bladder
• Stones noted on a film as filling defect in a visualized opacified gall bladder
• However, this test has been replaced by ultrasonography

9. Ultrasonography
• IOC for acute calculus cholecystitis, chronic cholecystitis and
cholelithiasis
• Operator dependent and may be suboptimal due to excessive body
fat and intraluminal bowel gas
• Can demonstrate- Biliary Calculi, Size of GB and CBD, Thickness of GB
wall, inflammation around GB, presence of stones within biliary tree

10. HIDA Scan
• Technetium -99m labelled derivative of imino-diacetic acid are when
injected intravenously, selectively taken up by reticulo-endothelial
cells of the liver and excreted into bile.
• Allows visualization of biliary tree and gall bladder
• GB visualized within 30 mins of isotope injection in 90 % cases
• Bowel seen within 1 hour of injection
• Non-visualization of GB suggestive of acute cholecystitis
• Helpful in diagnosing bile leaks and iatrogenic biliary obstruction

11. Complications
IN Gallbladder
• Silent stones
• Acute Cholecystitis
• Chronic Cholecystitis
• Mucocele
• Empyema
• Perforation
• Gangrene
• Carcinoms
In Bile Duct
• Obstructive Jaundice
• Cholangitis
• Acute Pancreatitis
In Intestine
• Gall Stone Ileus

12. Treatment
• Cholecystectomy
• Open VS Laparoscopic Cholecystectomy ( Surgical)
MEDICAL THERAPY (?? EFFECTIVENESS)

13. To be continued !!!