This document discusses predisposing factors, pathogenesis, types, clinical features, complications, investigations, differential diagnosis, and management of gallstones. The main types are cholesterol stones, mixed stones, and pigment stones. Risk factors include obesity, female sex hormones, age, pregnancy, certain drugs, and diabetes. Gallstones can cause symptoms like biliary colic or be asymptomatic. Complications involve inflammation of the gallbladder or bile ducts. Treatment options are medical therapy with ursodeoxycholic acid for small cholesterol stones or laparoscopic cholecystectomy.

2. Predisposing factors
1. Obesity
2. Female sex hormones – estrogen & OCPs
3. Increasing age
4. Pregnancy
5. Drugs- octreotide, clofibrate
6. High fat diet
7. Diabetes mellitus

3. LITHOGENIC BILE
• Increase cholesterol-
obesity,diet
• Decrease bile acids-
OCPs,genetic
factors,PBC,ileal
disease,ileal resection
• Increase bilirubin-
Hemolytic Anemia
NUCLEATION
• Excess pronucleating
factors-e.g. mucin
• Decreased anti-
nucleating factors- e.g.
Apolipoproteins
STASIS OR
HYPOMOTILITY OF
GALL BLADDER
• OCPs
• Vagotomy
• Fasting
• Pregnancy
• Prolonged parenteral
nutrition

4. Types of Gall stones
1. Cholesterol stones – radiating crystal like appearance
2. Mixed stones- Most common type of stones;
contains cholesterol, calcium salts of phosphates and
carbonates, palmitate ,proteins and are multiple
faceted.
3. Pigment stones- small, black or greenish black, multiple and often
sludge like

5. Pigment stones
Black pigment stones
• Most common
• Formed in gall bladder
• Made of Calcium
bilirubinate,phosphate,bicarbona
te
• Common in hemolytic
disorders,cirrhosis
• Multiple , small & hard in
consistency
Brown pigment stones
• Rarely form in gall bladder
• Formed in bile duct
• Related to bile stasis &
infected bile
• E.coli, Bacteroides

6. Clinical features
• More common in females
• Fat,fertile,forty,flatulent
• 10% Gallstones are RADIO-OPAQUE
• Asymptomatic in 10 to 20% cases
• Symptoms-
• Biliary colic- Right hypochondrium & epigastrium, radiating to
chest,back & shoulder, severe , on & off, spasmodic, occurs within
hours after meal,usually self limiting and recurring,precipitated by
fatty meal.
• vomiting
• Fever
• Increased WBCs

7. • MURPHY’s SIGN
Patient winces in pain
with catch of breath
when inflamed gall
bladder strikes
palpating fingers on
inspiration

8. Complications of Gall stones
In Gall Bladder-
• Acute cholecystitis
• Chronic cholecystitis
• Empyema of gall bladder
• Mucocele gall bladder
• Perforation – leading to
biliary peritonitis
• Gangrene of gall bladder
• Carcinoma
In Bile duct-
• Obstructive jaundice
• Cholangitis
• Acute pancreatitis
In Intestine-
• Acute intestinal
obstruction

9. Management
Investigations
• USG abdomen – posterior acoustic
shadowing
• Plain X RAY abdomen
• LFT- Increased conjugated bilirubin
Increased Alkaline Phosphate,
GGT, 5’-Nucleotidase
• TLC

10. D/D of radio-opaque shadow on x-ray
• Renal stone
• Calcified 12th rib tip
• Phlebolith
• Faecolith
• Calcified lymph node
• Renal cell Ca -
calcification
• Calcified Adrenal tumor

11. Treatment
• Medical therapy-
• GALL STONE DISSOLUTION
• Ursodeoxycholic acid (UDCA) – with a functioning
Gall bladder with stone less than 10 mm
• 10-15 mg/kg/day
• Pigment stones are non responsive to medical
therapy

12. Surgical therapy
• Laparoscopic
cholecystectomy is ideal.
• Open cholecystectomy is
done if patient unfit for
laparoscopy through Right
Sub-costal(KOCHERS’s)
incision.