Cholelithiasis Gallstones

Epidemiology

• Risk factors: women. Native Americans, t age (usually 40 y). obesity, pregnancy. TPN. rapid weight loss, drugs (OCPs. estrogen, clofibrate. octreotide, ceftriaxone)

Pathogenesis

• Bile bile salts, phospholipids, cholesterol; T cholesterol saturation in bile • accelerated nucleation • gallbladder hypomotility gallstones

Types of gallstones

• Mixed (80%): multiple stones, mostly cholesterol, may calcify (15-20%)

• Cholesterol (10%): usually single stone, large, uncalcified

Black: unconjugated bilirubin (hence seen in chronic hemolysis) and calcium Brown: anaerobic infection of bile leading to T unconjugated bilirubin and calcium Clinical manifestations

• History: may be asymptomatic (symptoms develop in -2% y) biliary pain - episodic RUQ or epigastric abdominal pain that begins abruptly, is continuous. resolves slowly, and lasts for 30 min to 3 h associated nausea; may be precipitated by fatty foods

• Physical exam: afebrile. • RUQ tenderness or epigastric pain Diagnostic studies

• RUQ U S: Se & Sp -90-95%, can show complications (cholecystitis); should be performed only after fasting -8 h to ensure distended, bile-filled gallbladder

Treatment

• Cholecystectomy (usually laparoscopic) if symptomatic

• Oral dissolution therapy with ursodeoxycholic acid (rare) for mild, uncomplicated biliary pain or Pts who are not surgical candidates

Complications

• Cholecystitis (30% of symptomatic biliary pain — cholecystitis within 2 y)

• Choledocholithiasis — cholangitis or gallstone pancreatitis

• Cholecystoenteric fistula (stone erodes through gallbladder into bowel). Mirizzi's syndrome (stone in cystic duct compresses common hepatic duct — jaundice, biliary obstruction)

• Gallbladder carcinoma (1%)

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