There are two major types of gallstones: cholesterol and pigment stones. Cholesterol gallstones contain >50% cholesterol monohydrate. Pigment stones have <20% cholesterol and are composed primarily of calcium bilirubinate. In Western industrialized countries, >90% are cholesterol stones.
In the United States, the prevalence of gallstones is 7.9% in men and 16.6% in women. Predisposing factors include demographic/genetics, obesity, weight loss, female sex hormones, age, gallbladder hypomotility, pregnancy, ileal disease, chronic hemolysis, and cirrhosis.
Many gallstones are “silent,” i.e., present in asymptomatic pts. Symptoms occur when stones trigger inflammation or cause obstruction of the cystic or common bile ducts (CBDs). Major symptoms: (1) biliary colic-a severe steady ache in the RUQ or epigastrium that begins suddenly; often occurs 30-90 min after meals, lasts for several hours, and occasionally radiates to the right scapula or back; (2) nausea, vomiting. Physical examination may be normal or show epigastric or RUQ tenderness.
Occasionally, mild and transient elevations in bilirubin (<85 µmol/L [<5 mg/dL]) accompany biliary colic.
Only 10-15% of cholesterol gallstones are radiopaque. Ultrasonography is best diagnostic test. The oral cholecystogram has been largely replaced by ultrasound, but may be used to assess the patency of the cystic duct and gallbladder emptying function (Table 153-1 Diagnostic Evaluation of the Bile Ducts).
Includes peptic ulcer disease (PUD), gastroesophageal reflux, irritable bowel syndrome, and hepatitis.
| TREATMENT | ||
CholelithiasisIn asymptomatic pts, risk of developing complications requiring surgery is small. Elective cholecystectomy should be reserved for: (1) symptomatic pts (i.e., biliary colic despite low-fat diet); (2) persons with previous complications of cholelithiasis (see below); and (3) presence of an underlying condition predisposing to an increased risk of complications (calcified or porcelain gallbladder). Pts with gallstones >3 cm or with an anomalous gallbladder containing stones should also be considered for surgery. Laparoscopic cholecystectomy is minimally invasive and is the procedure of choice for most pts undergoing elective cholecystectomy. Oral dissolution agents (ursodeoxycholic acid) partially or completely dissolve small radiolucent stones in 50% of selected pts within 6-24 months. Because of the frequency of stone recurrence and the effectiveness of laparoscopic surgery, the role of oral dissolution therapy has been largely confined to pts who are not candidates for elective cholecystectomy. |