Gallstones are concretions that form in the biliary tract, usually in the gallbladder. Cholelithiasis refers to gallstones in the gallbladder, while choledocholithiasis refers to gallstones in the common bile duct. Treatment depends on whether gallstones are asymptomatic or symptomatic. Asymptomatic gallstones may be managed expectantly, while symptomatic gallstones usually require surgical removal of the gallbladder (cholecystectomy) or other interventions if complications occur.

1. ‫د‬.‫حجازى‬ ‫مصطفى‬

2. Cholelithiasis involves the presence of
gallstones, which are concretions that form
in the biliary tract, usually in the
gallbladder.
Choledocholithiasis refers to the presence
of 1 or more gallstones in the common bile
duct (CBD).
Treatment of gallstones depends on the
stage of disease.

3. Gallstone disease may be thought of as
having the following 4 stages:
Lithogenic state, in which conditions favor
gallstone formation
Asymptomatic gallstones
Symptomatic gallstones, characterized by
episodes of biliary colic
Complicated cholelithiasis

4. Symptoms and complications result from
effects occurring within the gallbladder or
from stones that escape the gallbladder to
lodge in the CBD.

5. Characteristics of biliary colic include the
following:
Sporadic and unpredictable episodes
Pain that is localized to the epigastrium or
right upper quadrant, sometimes radiating
to the right scapular tip

6. Pain that begins postprandially, is often
described as intense and dull, typically
lasts 1-5 hours, increases steadily over 10-
20 minutes, and then gradually wanes
Pain that is constant; not relieved by
emesis, antacids, defecation, flatus, or
positional changes; and sometimes
accompanied by diaphoresis, nausea, and
vomiting

7. Nonspecific symptoms (eg, indigestion,
dyspepsia, belching, or bloating)
Patients with the lithogenic state or
asymptomatic gallstones have no
abnormal findings on physical
examination.

8. Distinguishing uncomplicated biliary colic
from acute cholecystitis or other
complications is important.
Key findings that may be noted include the
following:
Uncomplicated biliary colic – Pain that is
poorly localized and visceral; an
essentially benign abdominal examination
without rebound or guarding; absence of
fever

9. Acute cholecystitis – Well-localized pain in
the right upper quadrant, usually with
rebound and guarding; positive Murphy
sign (nonspecific); frequent presence of
fever; absence of peritoneal signs;
frequent presence of tachycardia and
diaphoresis; in severe cases, absent or
hypoactive bowel sounds

10. The presence of fever, persistent
tachycardia, hypotension, or jaundice
necessitates a search for complications,
which may include the following:
Cholecystitis
Cholangitis
Pancreatitis
Other systemic cause

11. Patients with uncomplicated cholelithiasis
or simple biliary colic typically have normal
laboratory test results; laboratory studies
are generally not necessary unless
complications are suspected.

12. Blood tests, when indicated, may include
the following:
Complete blood count (CBC) with
differential
Liver function panel
Amylase
Lipase

13. Imaging modalities that may be useful
include the following:
Abdominal radiography (upright and
supine) – Used primarily to exclude other
causes of abdominal pain (eg, intestinal
obstruction)

14. Ultrasonography – The procedure of
choice in suspected gallbladder or biliary
disease

15. Endoscopic ultrasonography (EUS) – An
accurate and relatively noninvasive means
of identifying stones in the distal CBD
Laparoscopic ultrasonography –Promising
as a potential method for bile duct imaging
during laparoscopic cholecystectomy

16. Computed tomography (CT) – More
expensive and less sensitive than
ultrasonography for detecting gallbladder
stones, but superior for demonstrating
stones in the distal CBD

17. Magnetic resonance imaging (MRI) with
magnetic resonance
cholangiopancreatography (MRCP) –
Usually reserved for cases in which
choledocholithiasis is suspected
Scintigraphy – Highly accurate for the
diagnosis of cystic duct obstruction

18. Endoscopic retrograde
cholangiopancreatography (ERCP)
Percutaneous transhepatic
cholangiography (PTC)

19. The treatment of gallstones depends upon
the stage of disease, as follows:
Lithogenic state – Interventions are
currently limited to a few special
circumstances
Asymptomatic gallstones – Expectant
management

20. Symptomatic gallstones – Usually,
definitive surgical intervention (eg,
cholecystectomy), though medical
dissolution may be considered in some
cases

21. Medical treatments, used individually or in
combination, include the following:
Oral bile salt therapy (ursodeoxycholic
acid)
Contact dissolution
Extracorporeal shockwave lithotripsy

22. Cholecystectomy for asymptomatic
gallstones may be indicated in the
following patients:
Those with large (>2 cm) gallstones

23. Those who have a nonfunctional or
calcified (porcelain) gallbladder on imaging
studies and who are at high risk of
gallbladder carcinoma
Those with spinal cord injuries or sensory
neuropathies affecting the abdomen
Those with sickle cell anemia in whom the
distinction between painful crisis and
cholecystitis may be difficult

24. Patients with the following risk factors for
complications of gallstones may be offered
elective cholecystectomy, even if they have
asymptomatic gallstones:
Cirrhosis
Portal hypertension
Children
Transplant candidates
Diabetes with minor symptoms

25. Surgical interventions to be considered
include the following:
Cholecystectomy (open or laparoscopic)
Cholecystostomy
Endoscopic sphincterotomy

26. Oral bile acids have been used for years to
dissolve common duct stones.
The success rates, however, are variable,
ranging from 10% to 44%.

27. • In one randomized, double-blind,
placebo-controlled study, 28 patients with
uncomplicated, non-obstructing common
duct stones were treated with
ursodeoxycholic acid (12 mg/kg/d for up
to 2 years); the bile duct stones
disappeared in 7 of 14 patients in the
treatment group and 0 of 14 in the
placebo group.

28. Four patients (14%) required operative
intervention, including one from the treated
and three from the placebo groups.
Rowachol (a terpene preparation) is known
to further promote stone dissolution.


29. Currently, optimal patient
selection,duration of treatment, and
optimal dosing has not been determined
with these medical treatments of
choledocholithiasis.

30. The area in which oral bile acid therapy
may play a role is the treatment of
asymptomatic patients with small
cholesterol duct stones discovered during
laparoscopic cholecystectomy.

31. The composition of bile ductal stones may
be inferred if cholesterol stones were
present in the gallbladder, and small duct
stones might dissolve relatively rapidly.

32. Because duct exploration during
laparoscopic cholecystectomy might be
demanding technically, especially with a
small-diameter cystic and/or common bile
duct, this dissolution therapy is a
reasonable therapeutic alternative;
however, this approach needs to be
evaluated in clinical trials.

33. Cholelithiasis is the medical term for
gallstone disease.
Gallstones are concretions that form in the
biliary tract, usually in the gallbladder.

34. Cholelithiasis
A gallbladder filled with gallstones
(examined extracorporally after
laparoscopic cholecystectomy .
Gallstones develop insidiously, and they
may remain asymptomatic for decades.

35. Migration of a a gallstone into the opening
of the cystic duct may block the outflow of
bile during gallbladder contraction.

36. The resulting increase in gallbladder wall
tension produces a characteristic type of
pain (biliary colic).
Cystic duct obstruction, if it persists for
more than a few hours, may lead to acute
gallbladder inflammation (acute
cholecystitis).

37. Choledocholithiasis refers to the presence
of one or more gallstones in the common
bile duct.
Usually, this occurs when a gallstone
passes from the gallbladder into the
common bile duct .

38. Common bile duct stone
(choledocholithiasis)
 The sensitivity of transabdominal
ultrasonography for choledocholithiasis is
approximately 75% in the presence of
dilated ducts and 50% for nondilated
ducts.

39. A gallstone in the common bile duct may
impact distally in the ampulla of Vater, the
point where the common bile duct and
pancreatic duct join before opening into
the duodenum.
Obstruction of bile flow by a stone at this
critical point may lead to abdominal pain
and jaundice.

40. Stagnant bile above an obstructing bile
duct stone often becomes infected, and
bacteria can spread rapidly back up the
ductal system into the liver to produce a
life-threatening infection called ascending
cholangitis.

41. Obstruction of the pancreatic duct by a
gallstone in the ampulla of Vater also can
trigger activation of pancreatic digestive
enzymes within the pancreas itself, leading
to acute pancreatitis.[1, 2]

42. Chronically, gallstones in the gallbladder
may cause progressive fibrosis and loss of
function of the gallbladder, a condition
known as chronic cholecystitis.
Chronic cholecystitis predisposes
to gallbladder cancer.

43. Ultrasonography is the initial diagnostic
procedure of choice in most cases of
suspected gallbladder or biliary tract
disease .

44. The treatment of gallstones depends upon
the stage of disease.
Asymptomatic gallstones may be managed
expectantly.

45. Once gallstones become symptomatic,
definitive surgical intervention with excision
of the gallbladder (cholecystectomy) is
usually indicated.

46. Cholecystectomy is among the most
frequently performed abdominal surgical
procedures .
Complications of gallstone disease may
require specialized management to relieve
obstruction and infection