Skip to content

Cholelithiasis

Basics

  • Presence of cholesterol, pigment, or mixed stones within the gallbladder.
  • Pediatric: uncommon <10 years; mostly pigment stones linked to blood disorders.
  • Female predominance (2-3:1), prevalence increases with age.

Epidemiology

  • Incidence: 1-3% increase yearly; peaks in 7th decade.
  • Prevalence: 8-10% in US; 20% in >65 years.

Etiology & Pathophysiology

  • Multifactorial: genetic, metabolic, immune, environmental.
  • Bile supersaturated with cholesterol leads to microcrystal precipitation.
  • Gallbladder sludge acts as nidus.
  • Pigment stones: black (hemolysis/cirrhosis), brown (infection/stasis).
  • Biliary stasis and impaired motility enhance stone formation.

Risk Factors

  • Age 60-80 years, female sex, pregnancy, multiparity, obesity, metabolic syndrome.
  • Ethnicity: Caucasian, Hispanic, Native American.
  • High-fat diet, cholestasis, TPN, vagotomy, somatostatin therapy, rapid weight loss.
  • Hemolytic diseases, IBD, terminal ileal resection.
  • Medications: oral contraceptives, high-dose steroids.
  • Viral hepatitis, biliary infection, biliary strictures.

Prevention

  • Regular exercise, dietary modification.
  • Statins may reduce cholesterol saturation.
  • Ursodiol during rapid weight loss.

Associated Conditions

  • 90% of gallbladder carcinoma patients have gallstones and chronic cholecystitis.

Diagnosis

History

  • Mostly asymptomatic (80%).
  • Biliary colic: episodic RUQ or epigastric pain >15 minutes, postprandial (fatty meals), radiates to back.
  • Nausea, vomiting, indigestion, fatty food intolerance.
  • Gallstone complications (e.g., pancreatitis) may be first presentation.

Physical Exam

  • Often normal unless acute attack.
  • Murphy sign: RUQ tenderness, variable sensitivity/specificity.
  • Charcot triad: fever, jaundice, RUQ pain (cholangitis).
  • Reynolds pentad adds hemodynamic instability, mental changes.
  • Cullen and Grey Turner signs in hemorrhagic pancreatitis.
  • Courvoisier sign suggests malignant obstruction.

Differential Diagnosis

  • Peptic ulcer disease, gastritis, hepatitis.
  • Pancreatitis, cholangitis, gallbladder cancer.
  • Acalculous cholecystitis, biliary dyskinesia, choledocholithiasis.

Diagnostic Tests

  • Ultrasound: preferred (97-98% sensitivity).
  • Gallbladder wall thickening, pericholecystic fluid, sonographic Murphy sign for cholecystitis.
  • CT: limited for gallstones; better for distal CBD stones.
  • MRCP: for suspected CBD stones.
  • Endoscopic US: comparable to ERCP for CBD stones.
  • HIDA scan: diagnoses cystic duct obstruction and differentiates acalculous cholecystitis.
  • 10-30% stones radiopaque on X-ray.
  • Porcelain gallbladder associated with cancer risk.

Treatment

General Measures

  • Treat symptomatic patients.
  • Conservative treatment in pregnancy; surgery preferably in 2nd trimester.
  • Prophylactic cholecystectomy for porcelain gallbladder, large stones (≥3 cm), sickle cell disease, children with stones, recurrent pancreatitis.
  • Combined cholecystectomy with bariatric surgery in morbid obesity.

Medications

  • NSAIDs first choice for pain; opioids if needed.
  • Antibiotics for acute cholecystitis.
  • Prophylactic antibiotics not routinely required for laparoscopic cholecystectomy.

Surgery

  • Indicated for symptomatic stones or complications.
  • Laparoscopic cholecystectomy (LC) is gold standard.
  • Robotic cholecystectomy an alternative, higher cost, no clear benefit.
  • IOC detects CBD stones intraoperatively.
  • Early LC (<24 hours for biliary colic, <7 days for cholecystitis) shortens hospital stay.
  • Percutaneous cholecystostomy for high-risk or unfit patients; followed by interval cholecystectomy.
  • Oral ursodiol for nonsurgical candidates with small stones; >50% recurrence after stopping.
  • Cystic duct stenting via ERCP for severe cholecystitis in non-surgical patients.
  • Shock wave lithotripsy for large bile duct stones before ERCP.

Admission and Nursing

  • Outpatient for uncomplicated cases.
  • Inpatient for complications (cholecystitis, cholangitis, pancreatitis).
  • Acute phase: NPO, IV fluids, antibiotics, analgesia.

Ongoing Care

  • Monitor symptoms.
  • Follow-up with labs and imaging if on dissolution therapy.

Diet

  • Low-fat diet may help symptom control.

Patient Education

  • Lifestyle modifications: exercise, dietary fat and calorie reduction.
  • Educate asymptomatic patients on biliary colic symptoms.

Prognosis

  • <50% become symptomatic.
  • Elective cholecystectomy mortality <0.5%; emergency 3-5%.
  • Morbidity <10% elective; 30-40% emergency.
  • 10-15% have choledocholithiasis.
  • Recurrence possible post-cholecystectomy in high-risk patients.

Complications

  • Acute cholecystitis (90-95% due to stones).
  • Gallstone pancreatitis.
  • Choledocholithiasis, cholangitis.
  • Biliary-enteric fistula, gallstone ileus.
  • Gallbladder cancer, Mirizzi syndrome.

Clinical Pearls: - Most gallstones asymptomatic. - Ultrasound is imaging modality of choice. - LC preferred for symptomatic disease. - Acalculous cholecystitis linked to bile stasis and ischemia. - Prophylactic cholecystectomy not routinely indicated for asymptomatic stones.