What are gallstones?
•Small, pebble-like substances
•Multiple or solitary
•May occur anywhere within the biliary tree
•Have different appearance - depending on their contents
Types of Gall stones
1.Cholesterol stones
2.Pigment stones
3.Mixed stones
Cholesterol stones
•Large
•Often solitary
•Yellow, white or green
•Made primarily of cholesterol (>70%)
•Risk factors:
–4 “F” :
•Female
•Forty
•Fertile
•Fat
–Fair (5th “F” - more prevalent in Caucasians)
–Family history (6th “F”)
Pigment stones
•Small
•Friable
•Irregular
•Dark
•Made of bilirubin and calcium salts
•Less than 20% of cholesterol
•Risk factors:
–Haemolysis
–Liver cirrhosis
–Biliary tract infections
–Ileal resection
Mixed stones
•Multiple
•Faceted
•Consist of:
–Calcium salts
–Pigment
–Cholesterol (30% - 70%)
•80% - associated with chronic cholecystitis
Anatomy of gallbladder and extrahepatic biliary tree
Calot’sTraingle
The boundaries of Calot’s triangle are:
1.Common hepatic duct
2.Cystic duct
3.Inferior border of the liver.
It contains:
•Cystic lymph node
•Cystic artery
What is Bile?
•Bile
–Helps the body digest fats
–Made in the liver
–Stored in the gallbladder until the body needs it
–Contains:
•Water
•Cholesterol
•Bile pigments
•Phospholipids
•Bicarbonate
•Anions of the bile acids
•Concentrations vary - different kinds of stones may be formed
• Daily up to 1000 ml of bile is secreted from the liver which contains water (98%), bile salts, bile pigments, with a pH more than 7.0.
• Main function of gallbladder is to concentrate and store the bile. Capacity of gallbladder is 40-50 ml.
• Bile salts form micelle which makes cholesterol soluble. Bile salts (i.e. salts of cholic and chenodeoxycholic acids) with formed deoxycholic acid (in the bowel) enters the enterohepatic circulation to get resecreted in the bile.
• Bilirubin conjugated in the liver is secreted into the bile, which in the bowel is converted into urobilinogen by bacteria. Urobilinogen gets absorbed in the bowel, enters the liver for resecretion again and part of it is excreted in the urine. Absence of urobilinogen in the urine signifies obstructive jaundice.
• In the absence of gallstones or any other disease, bile is sterile.
Causes of Gall Stones
1.ALTERED GB FUNCTION
a.Stasis of bile
i.Oestrogen therapy
ii.Pregnancy
iii.TPN (IV nutrition)
iv.Vagotomy (Surgery for peptic ulcers)
b.Poor emptying
c.Poor absorption
d.Infection
2.SUPERSATURATED BILE
a.Female
b.Fat
c.Fertile
d.Forty
e.High calorie intake
3.ALTERED ENTERO-HEPATIC CIRCULATION
a.Ileal resection
b.Ileal diseases
c.Altered bowel transit time
d.Altered bowel flora
e.Cholestyramine
f.Deoxycholate
4.HAEMOLYTIC CAUSES OF INCREASED BILIRUBIN PRODUCTION
a.Sickle cell anemia
b.Hereditary spherocytosis
c.Thalassemia
d.Malaria
e.Liver cirrhosis
5.INFECTIONS
a.Bacterial – E. Coli, Salmonella
b.Parasitic – Clonorchis sinensis (Liver fluke), Ascaris lumbricoides (Round worms)
Complications of gallstones
•In the GB:
–Biliary colic
–Acute and chronic cholecystitis
–Empyema
–Mucocoele
–Carcinoma
•In the bile ducts:
–Obstructive jaundice
–Pancreatitis
–Cholangitis
•In the gut:
–Gallstone ileus
Symptoms
Diagnosis
•Ultrasound
–Most sensitive and specific test for gallstones
•Computerized tomography (CT) scan
–May show gallstones or complications, such as infection and rupture of GB or bile ducts
•Magnetic Resonance Cholangio-pancreatography (MRCP)
– Gold standard investigation
•Cholescintigraphy (HIDA scan) Used to diagnose abnormal contraction of gallbladder or obstruction of bile ducts
•Endoscopic retrograde cholangiopancreatography (ERCP)
–Used to locate and remove stones in bile ducts
•Blood tests
–Performed to look for signs of infection, obstruction, pancreatitis, or jaundice
Image: MRCP RECONSTRUCTION OF BILIARY TREE
Treatment
Surgery: Cholecystectomy (gallbladder removal)
Two surgical options
–Open cholecystectomy
–Laparoscopic cholecystectomy - Golden standard of care.
•Nonsurgical treatment: DOESN’T USUALLY WORK!
–Only in special situations
•When a patient has a serious medical condition preventing surgery
•Only for cholesterol stones
–Oral dissolution therapy
•Ursodeoxycholic acid- to dissolve cholesterol gallstones
•Months or years of treatment may be necessary before all stones dissolve
–Contact dissolution therapy
•Experimental procedure
•Involves injecting a drug directly into the gallbladder to dissolve cholesterol stones
Please feel free to contact me here if you have any queries regarding gall stones.
To book an appointment online click here