Cholelithiasis, also known as gallstones, are solidified deposits of digestive fluid that can form within the gallbladder. The gallbladder serves as a reservoir for bile, a digestive fluid released into the small intestine. For individuals with asymptomatic gallstones incidentally discovered, the risk of developing symptoms or complications stands at 1% to 2% per year.
In cases where these asymptomatic gallstones are detected in an otherwise healthy gallbladder and a normal biliary tree, treatment is generally unnecessary unless symptoms manifest. Nevertheless, approximately 20% of these asymptomatic gallstones will eventually become symptomatic over a 15-year follow-up period. Subsequently, these gallstones may progress to more severe complications, including cholecystitis, choledocholithiasis, cholangitis, gallstone pancreatitis, and, in rare instances, cholangiocarcinoma.
Epidemiology
Cholelithiasis is a relatively common condition, affecting approximately 6% of men and 9% of women. The highest prevalence of gallstones is observed in Native American populations, while their occurrence is less frequent in Africa and Asia. The increasing prevalence of obesity is believed to have contributed to the rising incidence of gallstones.
Despite the relatively high occurrence of gallstones, more than 80% of individuals with this condition do not experience any symptoms. However, about 1% to 2% of previously asymptomatic individuals may develop biliary pain annually. A small percentage of those who begin to experience symptoms may face significant complications such as cholecystitis, choledocholithiasis, gallstone pancreatitis, and cholangitis, with an estimated yearly incidence of 0.1% to 0.3%.
Anatomy
Pathophysiology
Gallstones form when there is an imbalance in the constituents of bile. Bile contains cholesterol, bilirubin, and bile salts. An excess of cholesterol or bilirubin relative to the amount of bile salts can lead to the precipitation of these substances and the formation of gallstones. The most common type of gallstones are cholesterol stones, which are primarily composed of cholesterol.
Elevated levels of cholesterol in bile can result from various factors, including genetics, diet, obesity, and certain medical conditions. Cholesterol supersaturation in bile promotes the formation of cholesterol crystals, which can aggregate and grow into stones over time. Gallstones are more likely to form when bile within the gallbladder becomes stagnant or does not empty properly.
Prolonged stasis allows for the precipitation and aggregation of cholesterol crystals or bilirubin, contributing to stone formation. Altered gallbladder motility, which may be influenced by factors such as obesity or pregnancy, can contribute to the development of gallstones. A sluggish gallbladder may not contract effectively to release bile, leading to bile stasis and stone formation.
Etiology
Obesity: Obesity is a significant risk factor for cholelithiasis. Excess body weight can lead to increased cholesterol levels in bile and reduced gallbladder emptying, promoting stone formation.
Dietary Factors: A diet high in saturated fats and cholesterol and low in fiber can contribute to gallstone formation. Healthy dietary choices can help reduce the risk.
Age and Gender: Cholelithiasis is more common in older individuals and women, especially during pregnancy and in those taking hormone replacement therapy.
Lifestyle Factors: Sedentary lifestyles and a lack of physical activity can contribute to gallstone formation.
Pregnancy: Pregnancy can increase the risk of gallstones due to hormonal changes that affect the gallbladder’s function.
Genetics
Prognostic Factors
Clinical History
Patients who have gallstone disease experience symptoms known as biliary colic. These symptoms include intermittent bouts of constant, sharp abdominal pain in the right upper quadrant of the abdomen. These episodes are often accompanied by feelings of nausea and vomiting. Patients may also sweat excessively during these painful episodes.
The pain tends to be triggered by the consumption of fatty meals, causing the gallbladder to contract. Typically, the pain begins within an hour after eating a meal rich in fats. It is often described as dull and intense and can persist for a duration ranging from 1 to 5 hours. However, it’s worth noting that not all patients with gallstone disease experience pain directly associated with meals.
In a significant number of cases, the pain can occur at night. The frequency of these recurrent episodes can vary among individuals, with most patients not experiencing symptoms daily. This intermittent pattern of pain is a characteristic feature of biliary colic in gallstone disease.
Physical Examination
Acute cholecystitis occurs when a gallstone becomes lodged in the cystic duct, causing the gallbladder to become swollen and inflamed. In addition to abdominal pain in the right upper quadrant, patients may also exhibit fever and tenderness when pressure is applied over the gallbladder area, a clinical sign known as Murphy’s sign.
When patients with gallstone disease present with symptoms such as fever, tachycardia, hypotension, or jaundice, it necessitates investigating potential complications of cholelithiasis. These complications include cholangitis, cholecystitis, pancreatitis, or other systemic causes.
Cholangitis occurs when bacteria colonize and proliferate in stagnant bile above an obstructed common bile duct stone. This leads to purulent inflammation in both the liver and the biliary tree. A classic clinical presentation for cholangitis is known as Charcot’s triad, which consists of severe tenderness in the right upper quadrant of the abdomen, fever, and jaundice.
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Differential Diagnoses
Acute Pancreatitis
Bile Duct Tumors
Esophageal Spasm
Gallbladder Cancer
Hepatitis
Irritable Bowel Syndrome
Pancreatitis
Peptic Ulcer Disease
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
The treatment approach for gallstones is contingent on the stage of the disease. When gallstones become symptomatic, the typical course of action is definitive surgical intervention through cholecystectomy. However, there are specific criteria for carefully selecting patients for this surgical procedure. Patients with gallstones that are smaller in size (usually less than 0.5 to 1 cm), exhibit good gallbladder function, and have minimal to no calcification may meet these criteria for surgical intervention.
In cases of complicated cholecystitis, the initial focus is on stabilizing the patient’s condition and, if necessary, draining the gallbladder before proceeding with cholecystectomy. The role of medical management for gallstones has diminished in recent years. Nonetheless, in certain circumstances, it can serve as a viable alternative to cholecystectomy.
This approach is particularly considered for patients who are not suitable candidates for surgery or those who are reluctant to undergo it. Pharmacological treatment options include the use of bile salts, such as ursodeoxycholic acid, to prevent the formation of gallstones. In summary, the treatment of gallstones depends on the stage of the disease.
Symptomatic gallstones often require cholecystectomy, but careful patient selection is necessary. In cases of complicated cholecystitis, stabilization and drainage may precede surgery. While medical management’s role has diminished, it can be considered for select patients, primarily for gallstone prevention using medications like ursodeoxycholic acid.
by Stage
by Modality
Chemotherapy
Radiation Therapy
Surgical Interventions
Cholecystectomy
Patients with symptoms and diagnostic findings indicative of acute cholecystitis must be admitted to the hospital. They should receive a surgical consultation and be administered intravenous antibiotics. In cases where patients are diagnosed with choledocholithiasis or gallstone pancreatitis, hospitalization is also necessary. I
n such instances, it’s important to involve a gastrointestinal specialist for consultation, and procedures like ERCP (Endoscopic Retrograde Cholangiopancreatography) or MRCP (Magnetic Resonance Cholangiopancreatography) may be required. For patients experiencing acute ascending cholangitis, their condition is typically severe, and they may appear visibly ill and septic.
In these critical cases, a high level of medical intervention is essential. Aggressive resuscitation measures should be taken, often requiring intensive care unit (ICU)-level care. Additionally, surgical intervention may be necessary to address the infection within the biliary tract and facilitate drainage.
Endoscopic Sphincterotomy
When the immediate surgical removal of common bile duct stones is not viable, endoscopic retrograde sphincterotomy becomes a valuable alternative. This procedure proves particularly beneficial for critically ill patients suffering from ascending cholangitis resulting from the obstruction of the ampulla of Vater by a gallstone. It serves the purpose of preventing the recurrence of acute gallstone pancreatitis and other complications associated with choledocholithiasis in patients who are not suitable candidates for elective cholecystectomy or have a bleak long-term prognosis.
Hormone Therapy
Immunotherapy
Hyperthermia
Photodynamic Therapy
Stem Cell Transplant
Targeted Therapy
Palliative Care
Phase of Management
Asymptomatic
Gallstones can exist within the gallbladder for many years without triggering symptoms or complications. Patients with asymptomatic gallstones should receive counseling about the symptoms of biliary colic and when to seek medical help. When cholelithiasis occurs without any complications, it can be managed with either oral or injectable analgesics as required.
Symptomatic
In individuals with symptomatic gallstones, the removal of the gallbladder (cholecystectomy) is typically recommended for those who have encountered symptoms or complications related to gallstones, unless the patient’s age and overall health pose excessive surgical risks.
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Cholelithiasis, also known as gallstones, are solidified deposits of digestive fluid that can form within the gallbladder. The gallbladder serves as a reservoir for bile, a digestive fluid released into the small intestine. For individuals with asymptomatic gallstones incidentally discovered, the risk of developing symptoms or complications stands at 1% to 2% per year.
In cases where these asymptomatic gallstones are detected in an otherwise healthy gallbladder and a normal biliary tree, treatment is generally unnecessary unless symptoms manifest. Nevertheless, approximately 20% of these asymptomatic gallstones will eventually become symptomatic over a 15-year follow-up period. Subsequently, these gallstones may progress to more severe complications, including cholecystitis, choledocholithiasis, cholangitis, gallstone pancreatitis, and, in rare instances, cholangiocarcinoma.
Cholelithiasis is a relatively common condition, affecting approximately 6% of men and 9% of women. The highest prevalence of gallstones is observed in Native American populations, while their occurrence is less frequent in Africa and Asia. The increasing prevalence of obesity is believed to have contributed to the rising incidence of gallstones.
Despite the relatively high occurrence of gallstones, more than 80% of individuals with this condition do not experience any symptoms. However, about 1% to 2% of previously asymptomatic individuals may develop biliary pain annually. A small percentage of those who begin to experience symptoms may face significant complications such as cholecystitis, choledocholithiasis, gallstone pancreatitis, and cholangitis, with an estimated yearly incidence of 0.1% to 0.3%.
Gallstones form when there is an imbalance in the constituents of bile. Bile contains cholesterol, bilirubin, and bile salts. An excess of cholesterol or bilirubin relative to the amount of bile salts can lead to the precipitation of these substances and the formation of gallstones. The most common type of gallstones are cholesterol stones, which are primarily composed of cholesterol.
Elevated levels of cholesterol in bile can result from various factors, including genetics, diet, obesity, and certain medical conditions. Cholesterol supersaturation in bile promotes the formation of cholesterol crystals, which can aggregate and grow into stones over time. Gallstones are more likely to form when bile within the gallbladder becomes stagnant or does not empty properly.
Prolonged stasis allows for the precipitation and aggregation of cholesterol crystals or bilirubin, contributing to stone formation. Altered gallbladder motility, which may be influenced by factors such as obesity or pregnancy, can contribute to the development of gallstones. A sluggish gallbladder may not contract effectively to release bile, leading to bile stasis and stone formation.
Obesity: Obesity is a significant risk factor for cholelithiasis. Excess body weight can lead to increased cholesterol levels in bile and reduced gallbladder emptying, promoting stone formation.
Dietary Factors: A diet high in saturated fats and cholesterol and low in fiber can contribute to gallstone formation. Healthy dietary choices can help reduce the risk.
Age and Gender: Cholelithiasis is more common in older individuals and women, especially during pregnancy and in those taking hormone replacement therapy.
Lifestyle Factors: Sedentary lifestyles and a lack of physical activity can contribute to gallstone formation.
Pregnancy: Pregnancy can increase the risk of gallstones due to hormonal changes that affect the gallbladder’s function.
Patients who have gallstone disease experience symptoms known as biliary colic. These symptoms include intermittent bouts of constant, sharp abdominal pain in the right upper quadrant of the abdomen. These episodes are often accompanied by feelings of nausea and vomiting. Patients may also sweat excessively during these painful episodes.
The pain tends to be triggered by the consumption of fatty meals, causing the gallbladder to contract. Typically, the pain begins within an hour after eating a meal rich in fats. It is often described as dull and intense and can persist for a duration ranging from 1 to 5 hours. However, it’s worth noting that not all patients with gallstone disease experience pain directly associated with meals.
In a significant number of cases, the pain can occur at night. The frequency of these recurrent episodes can vary among individuals, with most patients not experiencing symptoms daily. This intermittent pattern of pain is a characteristic feature of biliary colic in gallstone disease.
Acute cholecystitis occurs when a gallstone becomes lodged in the cystic duct, causing the gallbladder to become swollen and inflamed. In addition to abdominal pain in the right upper quadrant, patients may also exhibit fever and tenderness when pressure is applied over the gallbladder area, a clinical sign known as Murphy’s sign.
When patients with gallstone disease present with symptoms such as fever, tachycardia, hypotension, or jaundice, it necessitates investigating potential complications of cholelithiasis. These complications include cholangitis, cholecystitis, pancreatitis, or other systemic causes.
Cholangitis occurs when bacteria colonize and proliferate in stagnant bile above an obstructed common bile duct stone. This leads to purulent inflammation in both the liver and the biliary tree. A classic clinical presentation for cholangitis is known as Charcot’s triad, which consists of severe tenderness in the right upper quadrant of the abdomen, fever, and jaundice.
Acute Pancreatitis
Bile Duct Tumors
Esophageal Spasm
Gallbladder Cancer
Hepatitis
Irritable Bowel Syndrome
Pancreatitis
Peptic Ulcer Disease
The treatment approach for gallstones is contingent on the stage of the disease. When gallstones become symptomatic, the typical course of action is definitive surgical intervention through cholecystectomy. However, there are specific criteria for carefully selecting patients for this surgical procedure. Patients with gallstones that are smaller in size (usually less than 0.5 to 1 cm), exhibit good gallbladder function, and have minimal to no calcification may meet these criteria for surgical intervention.
In cases of complicated cholecystitis, the initial focus is on stabilizing the patient’s condition and, if necessary, draining the gallbladder before proceeding with cholecystectomy. The role of medical management for gallstones has diminished in recent years. Nonetheless, in certain circumstances, it can serve as a viable alternative to cholecystectomy.
This approach is particularly considered for patients who are not suitable candidates for surgery or those who are reluctant to undergo it. Pharmacological treatment options include the use of bile salts, such as ursodeoxycholic acid, to prevent the formation of gallstones. In summary, the treatment of gallstones depends on the stage of the disease.
Symptomatic gallstones often require cholecystectomy, but careful patient selection is necessary. In cases of complicated cholecystitis, stabilization and drainage may precede surgery. While medical management’s role has diminished, it can be considered for select patients, primarily for gallstone prevention using medications like ursodeoxycholic acid.
Cholecystectomy
Patients with symptoms and diagnostic findings indicative of acute cholecystitis must be admitted to the hospital. They should receive a surgical consultation and be administered intravenous antibiotics. In cases where patients are diagnosed with choledocholithiasis or gallstone pancreatitis, hospitalization is also necessary. I
n such instances, it’s important to involve a gastrointestinal specialist for consultation, and procedures like ERCP (Endoscopic Retrograde Cholangiopancreatography) or MRCP (Magnetic Resonance Cholangiopancreatography) may be required. For patients experiencing acute ascending cholangitis, their condition is typically severe, and they may appear visibly ill and septic.
In these critical cases, a high level of medical intervention is essential. Aggressive resuscitation measures should be taken, often requiring intensive care unit (ICU)-level care. Additionally, surgical intervention may be necessary to address the infection within the biliary tract and facilitate drainage.
Endoscopic Sphincterotomy
When the immediate surgical removal of common bile duct stones is not viable, endoscopic retrograde sphincterotomy becomes a valuable alternative. This procedure proves particularly beneficial for critically ill patients suffering from ascending cholangitis resulting from the obstruction of the ampulla of Vater by a gallstone. It serves the purpose of preventing the recurrence of acute gallstone pancreatitis and other complications associated with choledocholithiasis in patients who are not suitable candidates for elective cholecystectomy or have a bleak long-term prognosis.
Asymptomatic
Gallstones can exist within the gallbladder for many years without triggering symptoms or complications. Patients with asymptomatic gallstones should receive counseling about the symptoms of biliary colic and when to seek medical help. When cholelithiasis occurs without any complications, it can be managed with either oral or injectable analgesics as required.
Symptomatic
In individuals with symptomatic gallstones, the removal of the gallbladder (cholecystectomy) is typically recommended for those who have encountered symptoms or complications related to gallstones, unless the patient’s age and overall health pose excessive surgical risks.
medtigo
Cholelithiasis
Updated :
September 16, 2023
Cholelithiasis, also known as gallstones, are solidified deposits of digestive fluid that can form within the gallbladder. The gallbladder serves as a reservoir for bile, a digestive fluid released into the small intestine. For individuals with asymptomatic gallstones incidentally discovered, the risk of developing symptoms or complications stands at 1% to 2% per year.
In cases where these asymptomatic gallstones are detected in an otherwise healthy gallbladder and a normal biliary tree, treatment is generally unnecessary unless symptoms manifest. Nevertheless, approximately 20% of these asymptomatic gallstones will eventually become symptomatic over a 15-year follow-up period. Subsequently, these gallstones may progress to more severe complications, including cholecystitis, choledocholithiasis, cholangitis, gallstone pancreatitis, and, in rare instances, cholangiocarcinoma.
Cholelithiasis is a relatively common condition, affecting approximately 6% of men and 9% of women. The highest prevalence of gallstones is observed in Native American populations, while their occurrence is less frequent in Africa and Asia. The increasing prevalence of obesity is believed to have contributed to the rising incidence of gallstones.
Despite the relatively high occurrence of gallstones, more than 80% of individuals with this condition do not experience any symptoms. However, about 1% to 2% of previously asymptomatic individuals may develop biliary pain annually. A small percentage of those who begin to experience symptoms may face significant complications such as cholecystitis, choledocholithiasis, gallstone pancreatitis, and cholangitis, with an estimated yearly incidence of 0.1% to 0.3%.
Gallstones form when there is an imbalance in the constituents of bile. Bile contains cholesterol, bilirubin, and bile salts. An excess of cholesterol or bilirubin relative to the amount of bile salts can lead to the precipitation of these substances and the formation of gallstones. The most common type of gallstones are cholesterol stones, which are primarily composed of cholesterol.
Elevated levels of cholesterol in bile can result from various factors, including genetics, diet, obesity, and certain medical conditions. Cholesterol supersaturation in bile promotes the formation of cholesterol crystals, which can aggregate and grow into stones over time. Gallstones are more likely to form when bile within the gallbladder becomes stagnant or does not empty properly.
Prolonged stasis allows for the precipitation and aggregation of cholesterol crystals or bilirubin, contributing to stone formation. Altered gallbladder motility, which may be influenced by factors such as obesity or pregnancy, can contribute to the development of gallstones. A sluggish gallbladder may not contract effectively to release bile, leading to bile stasis and stone formation.
Obesity: Obesity is a significant risk factor for cholelithiasis. Excess body weight can lead to increased cholesterol levels in bile and reduced gallbladder emptying, promoting stone formation.
Dietary Factors: A diet high in saturated fats and cholesterol and low in fiber can contribute to gallstone formation. Healthy dietary choices can help reduce the risk.
Age and Gender: Cholelithiasis is more common in older individuals and women, especially during pregnancy and in those taking hormone replacement therapy.
Lifestyle Factors: Sedentary lifestyles and a lack of physical activity can contribute to gallstone formation.
Pregnancy: Pregnancy can increase the risk of gallstones due to hormonal changes that affect the gallbladder’s function.
Patients who have gallstone disease experience symptoms known as biliary colic. These symptoms include intermittent bouts of constant, sharp abdominal pain in the right upper quadrant of the abdomen. These episodes are often accompanied by feelings of nausea and vomiting. Patients may also sweat excessively during these painful episodes.
The pain tends to be triggered by the consumption of fatty meals, causing the gallbladder to contract. Typically, the pain begins within an hour after eating a meal rich in fats. It is often described as dull and intense and can persist for a duration ranging from 1 to 5 hours. However, it’s worth noting that not all patients with gallstone disease experience pain directly associated with meals.
In a significant number of cases, the pain can occur at night. The frequency of these recurrent episodes can vary among individuals, with most patients not experiencing symptoms daily. This intermittent pattern of pain is a characteristic feature of biliary colic in gallstone disease.
Acute cholecystitis occurs when a gallstone becomes lodged in the cystic duct, causing the gallbladder to become swollen and inflamed. In addition to abdominal pain in the right upper quadrant, patients may also exhibit fever and tenderness when pressure is applied over the gallbladder area, a clinical sign known as Murphy’s sign.
When patients with gallstone disease present with symptoms such as fever, tachycardia, hypotension, or jaundice, it necessitates investigating potential complications of cholelithiasis. These complications include cholangitis, cholecystitis, pancreatitis, or other systemic causes.
Cholangitis occurs when bacteria colonize and proliferate in stagnant bile above an obstructed common bile duct stone. This leads to purulent inflammation in both the liver and the biliary tree. A classic clinical presentation for cholangitis is known as Charcot’s triad, which consists of severe tenderness in the right upper quadrant of the abdomen, fever, and jaundice.
Acute Pancreatitis
Bile Duct Tumors
Esophageal Spasm
Gallbladder Cancer
Hepatitis
Irritable Bowel Syndrome
Pancreatitis
Peptic Ulcer Disease
The treatment approach for gallstones is contingent on the stage of the disease. When gallstones become symptomatic, the typical course of action is definitive surgical intervention through cholecystectomy. However, there are specific criteria for carefully selecting patients for this surgical procedure. Patients with gallstones that are smaller in size (usually less than 0.5 to 1 cm), exhibit good gallbladder function, and have minimal to no calcification may meet these criteria for surgical intervention.
In cases of complicated cholecystitis, the initial focus is on stabilizing the patient’s condition and, if necessary, draining the gallbladder before proceeding with cholecystectomy. The role of medical management for gallstones has diminished in recent years. Nonetheless, in certain circumstances, it can serve as a viable alternative to cholecystectomy.
This approach is particularly considered for patients who are not suitable candidates for surgery or those who are reluctant to undergo it. Pharmacological treatment options include the use of bile salts, such as ursodeoxycholic acid, to prevent the formation of gallstones. In summary, the treatment of gallstones depends on the stage of the disease.
Symptomatic gallstones often require cholecystectomy, but careful patient selection is necessary. In cases of complicated cholecystitis, stabilization and drainage may precede surgery. While medical management’s role has diminished, it can be considered for select patients, primarily for gallstone prevention using medications like ursodeoxycholic acid.
Cholecystectomy
Patients with symptoms and diagnostic findings indicative of acute cholecystitis must be admitted to the hospital. They should receive a surgical consultation and be administered intravenous antibiotics. In cases where patients are diagnosed with choledocholithiasis or gallstone pancreatitis, hospitalization is also necessary. I
n such instances, it’s important to involve a gastrointestinal specialist for consultation, and procedures like ERCP (Endoscopic Retrograde Cholangiopancreatography) or MRCP (Magnetic Resonance Cholangiopancreatography) may be required. For patients experiencing acute ascending cholangitis, their condition is typically severe, and they may appear visibly ill and septic.
In these critical cases, a high level of medical intervention is essential. Aggressive resuscitation measures should be taken, often requiring intensive care unit (ICU)-level care. Additionally, surgical intervention may be necessary to address the infection within the biliary tract and facilitate drainage.
Endoscopic Sphincterotomy
When the immediate surgical removal of common bile duct stones is not viable, endoscopic retrograde sphincterotomy becomes a valuable alternative. This procedure proves particularly beneficial for critically ill patients suffering from ascending cholangitis resulting from the obstruction of the ampulla of Vater by a gallstone. It serves the purpose of preventing the recurrence of acute gallstone pancreatitis and other complications associated with choledocholithiasis in patients who are not suitable candidates for elective cholecystectomy or have a bleak long-term prognosis.
Gastroenterology
Asymptomatic
Gallstones can exist within the gallbladder for many years without triggering symptoms or complications. Patients with asymptomatic gallstones should receive counseling about the symptoms of biliary colic and when to seek medical help. When cholelithiasis occurs without any complications, it can be managed with either oral or injectable analgesics as required.
Symptomatic
In individuals with symptomatic gallstones, the removal of the gallbladder (cholecystectomy) is typically recommended for those who have encountered symptoms or complications related to gallstones, unless the patient’s age and overall health pose excessive surgical risks.
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