CHOLELITHIASIS AND CHOLECYSTITIS – Types, Etiology, Pathophysiology, Signs and Symptoms, Diagnostic Evaluation and Management
It refers to presence of stones in gallbladder. A gallstone is crystalline concretion formed within the gallbladder by accretion of bile components. These calculi are formed in the gallbladder but may distally pass into other parts of the bilary tract and sometimes if the stones may obstruct the flow of bile and will cause inflammation of gallbladder called cholecystitis
TYPES OF GALLSTONES
- Cholesterol stones: vary from light yellow to dark green or brown and are oval, between 2 and 3 cm long
- Pigment stones: pigment stones are small and dark and comprise bilirubin and calcium salts that are found in bile
- Mixed stones: mixed gallstones typically contain 20-80% of cholesterol
ETIOLOGY
- Gender: women are twice as likely as men to develop gallstones. Excess estrogen from pregnancy and hormone replacement therapy can lead to gallstones
- Family history: gallstones often run in families
- Obesity: obesity is a major risk factor for gallstones, especially in women
- Diet: diets high in fat and cholesterol and low in fiber increase the risk of gallstones
- Age: people older than age 60 are more likely to develop gallstones than younger people
- Hypolipidemic drugs: these drugs increase the amount of cholesterol secreted into bile and contribute to gallstones
- Hyperglycemia: people with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids may increase the risk of gallstones
PATHOPHYSIOLOGY
Gallstones —- pressure obstruction —- bile stasis —- ↓ fat emulsification (fat intolerance, anorexia, n/v, weight loss, gaseous eructation, flatulence, steatorrhea) —- Inflammation (Pain (RUQ), Fever, Leukocytosis) ↓ Bile flow into the colon, Acholic stool, ↓ vitamin K absorption —- ↑ S. bilirubin (Jaundice, Pruritus, tea-colored urine) —- Infections (cholecystitis and pancreatitis)
SIGNS AND SYMPTOMS
- Steady pain in the right upper abdomen that increases rapidly and lasts from 30 minutes to several hours
- Pain in the back
- Pain under the right shoulder
- Murphy’s sign (guarding type of respiratory pain radiates towards the back and scapula)
- Prolonged pain – more than 5 hours
- Nausea and vomiting
- Fever – even low-grade-or chills
- Yellowish color of the skin or whites of the eyes
- Clay-colored stools
DIAGNOSTIC EVALUATION
- Computerized tomography (CT) scans: the CT scan is a noninvasive X-ray that produces cross-section images of the body. The test may show the gallstones or complications, such as infection and rupture of the gallbladder or bile ducts
- Cholescintigraphy scan: patient is injected with a small amount of nonharmful radioactive material that is absorbed by the gallbladder which is then stimulated to contract. The test is used to diagnose abnormal contraction of the gallbladder or obstruction of the bile ducts
- Endoscopic retrograde cholangiopancreatography (ERCP): ERCP is used to locate and remove stones in the bile ducts. The doctor inserts an endoscope – a long, flexible, lighted tube with a camera-down the throat and through the stomach and into the small intestine. The endoscope is connected to a computer and video monitor. The doctor guides the endoscope and injects a special dye that helps the bile ducts appear better on the monitor. The endoscope helps the doctor locate the affected bile duct and the gallstone. The stone is captured in a tiny basket and removed with the endoscope
- Blood tests: blood tests may be performed to look for signs of infection, obstruction, pancreatitis, jaundice
MANAGEMENT
Pharmacological Management
- Opoids analgesic like mephridine, morphine
- Antispasmodic and anticholinergic
- Antiemetic
- Bile acid therapy
- Chenodeoxycholic acid reduces the cholesterol stone by maintaining a normal amount of cholesterol solubility in bile e.g. chenodiol
- Anticholelithiotic agents, like ursodiol
Surgical Management
- Extracorporeal shock wave lithotripsy: it is a noninvasive procedure used as an ambulatory treatment. A machine called lithotreptor generates a powerful shock to shatter the gallstones
- Percutaneous transhepatic biliary catheter insertion: insertion of a percutaneous transbiliary catheter under fluoroscopic guidance. This procedure will decompress obstructed extrahepatic ducts so that the bile can flow
Other surgical interventions are:
- Cholecystectomy
- Laparoscopic laser cholecystectomy
- Cholecystotomy
- Choledochotomy (incision of common bile duct)
- Choledocholithotomy (incision of common bile duct and removal of gallstones)
Nonsurgical Treatment
- Oral dissolution therapy: drugs made from bile acid are used to dissolve gallstones, e.g. ursodiol and chenodiol
- Contact dissolution therapy: this experimental procedure involves injecting a drug directly into the gallbladder to dissolve cholesterol stones. The drug methyl tert-butyl ether can dissolve some stones in 1 to 3 days
