Gallstones

GI Joe Gastroenterology Rounds

Gallbladder Disease

1. Gallstones: Types and Risk Factors

Gallstones are the most common type of gallbladder disease. They are primarily categorized by their composition:

• Cholesterol Stones: These are the "most common type in adults (composed of cholesterol monohydrate crystals)."
• Pigment Stones: These are composed of calcium bilirubinate crystals.
• Black Stones: Associated with "chronic hemolytic anemia."
• Brown Stones: Associated with "biliary stasis and infection."

Several factors increase the risk of developing gallstones:

• Demographic Factors: "older age, female gender, pregnancy and postpartum, obesity."
• Medical Conditions: "rapid weight loss, TPN, DM, cirrhosis, Crohn's disease."
• Medications: "estrogen, OCP, somatostatin analogues, ceftriaxone, clofibrate."

2. Clinical Presentation and Complications

While gallstones can be asymptomatic, they can lead to significant symptoms and complications.

• Asymptomatic Presentation: The risk of developing biliary pain in asymptomatic patients is low, at "2% per year."
• Biliary Pain: This is a hallmark symptom, characterized by a "rapid onset and is typically located in the epigastrium or the right upper quadrant." The pain is "constant and lasts for several hours," despite the misnomer "biliary colic" as it is "not colicky in nature."
• Other Complications:Cholecystitis: Inflammation of the gallbladder.
• Choledocholithiasis: Gallstones in the common bile duct.
• Cholangitis: Infection of the bile ducts.
• Gallstone Pancreatitis: Inflammation of the pancreas due to a gallstone.
• Rare Presentations:Mirizzi's Syndrome: An "impacted cystic duct stone obstructing the common hepatic duct."
• Gallstone Ileus: A "large gallstone obstructing the terminal ileum," entering through a gallbladder-enteric fistula.
• Bouveret's Syndrome: "Gastric outlet obstruction due to impaction of a gallstone in the pylorus or duodenum."

3. Diagnosis of Gallbladder Disease

• Gallbladder (GB) Ultrasound: This is the primary diagnostic tool, noted as "highly sensitive and specific for gallstones," though only "50% sensitive for choledocholithiasis."
• Other Tests: "CT, MRI/MRCP, EUS, ERCP, HIDA" can also be used depending on the suspected condition.

4. Treatment and Management

• Prophylactic Cholecystectomy (Gallbladder Removal):Not Recommended: Generally "not recommended for asymptomatic gallstones in the general population, nor in patients with diabetes or chronic hemolytic anemia."
• Recommended for Specific Groups:"Porcelain Gallbladder" (GB wall calcifications): Due to a significant risk of coexisting "GB malignancy" of "~ 20%."
• Abnormal Pancreatobiliary Junction: Increased risk of gallbladder cancer.
• GB Polyps > 10 mm.
• Astronauts: "before long duration space missions (controversial)."
• Morbidly Obese Patients Undergoing Bariatric Surgery: Cholecystectomy is "usually performed at the time of surgery." Ursodiol may be used to reduce gallstone formation in those not undergoing surgery.
• Patients Undergoing Resection of Small Intestinal Neuroendocrine Tumors: Especially if planned for treatment with somatostatin analogues, due to increased risk of cholelithiasis.
• Gallbladder Drainage (for sick cholecystitis patients): For patients too unwell for cholecystectomy, options include "percutaneous cholecystostomy, endoscopic ultrasound-guided gallbladder drainage, or endoscopic transpapillary drainage."

5. Post-Cholecystectomy Complications: Bile Leak

• Incidence: Bile leak is a complication in "~0.5-2.5% of laparoscopic cholecystectomies."
• Common Sites: The "cystic duct stump or the ducts of Luschka" are the most frequent sites of leakage.
• Diagnosis: Can be identified via "US, CT, HIDA, or increased bilirubin level in the peritoneal drain fluid."
• Treatment: Primarily managed by "ERCP with stent placement, with or without a sphincterotomy."