Cholelithiasis

Posted by e-Medical PPT Saturday, December 17, 2011
Three types of stones, cholesterol, pigment, mixed.Formation of each types is caused by crystallization of bile.
Cholesterol stones most common.
Bile consists of lethicin, bile acids, phospholipids in a fine balance.
Impaired motility can predispose to stones.
Sludge is crystals without stones. It may be a first step in stones, or be independent of it.
Pigment stones (15%) are from calcium bilirubinate. Diseases that increase RBC destruction will cause these. Also in cirrhotic patients, parasitic infections.
Every year 1-3% of patients develop symptoms.
Asymptomatic GS are not associated with fatalities.
Morbidity and mortality is associated only with symptomatic stones.
More common in women. Etiology may be secondary to variations in estrogen causing increased cholesterol secretion, and progesterone causing bile stasis.
Pregnant women more likely to have symptoms.
Women with multiple pregnancies at higher risk

Symptoms
3 clinical stages: asymptomatic, symptomatic, and with complications (cholecystitis, cholangitis, CBD stones).
Most (60-80%) are asymptomatic
A history of epigastric pain with radiation to shoulder may suggest it.
A detailed history of pattern and characteristics of symptoms as well as US make the diagnosis.
Most patients develop symptoms before complications.
Once symptoms occur, severe symptoms develop in 3-9%, with complications in 1-3% per year, and a cholecystectomy rate of 3-8% per year.
Indigestion, bloating, fatty food intolerance occur in similar frequencies in patients without gallstones, and are not cured with cholecystectomy.
Best definition of colic is pain that is severe in epigastrium or RUQ that last 1-5 hrs, often waking patient at night.
In classic cases pain is in the RUQ, however visceral pain and GB wall distension may be only in the epigastric area.
Once peritoneum irritated, localizes to RUQ. Small stones more symptomatic.

Signs
Vital signs and physical findings in asymptomatic cholelithiasis are completely normal.
Fever, tachycardia, hypotension, alert you to more serious infections, including cholangitis, cholecystitis.
Murphy’s sign

Workup
Elevated WBC is expected but not reliable.
In retrospective study, only 60% of patients with cholecytitis had a WBC greater than 11,000. A WBC greater than 15,000 may indicate perforation or gangrene.
ALT, AST, AP more suggestive of CBD stones
Amylase elevation may be GS pancreatitis.

Imaging Studies
US and Hida best. Plain x-rays, CT scans ERCP are adjuncts.
X-rays: 15% stones are radiopaque, porcelain GB may be seen. Air in biliary tree, emphysematous GB wall.
CT: for complications, ductal dilatation, surrounding organs. Misses 20% of GS. Get if diagnosis uncertain...

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