Cholelithiasis

Basics

Description

  • The presence of cholesterol, pigment, or mixed stones (calculi) within the gallbladder
  • Synonym(s): gallstones
Pediatric Considerations
  • Uncommon in children <10 years
  • Most gallstones in children are pigment stones associated with blood dyscrasias.

Epidemiology

Incidence
  • Increased in Native Americans and Hispanics
  • Increases with age ~1–3% per year; peaks at 7th decade
  • 2% of the U.S. population develops gallstones annually.

Prevalence
  • 8–10% of the U.S. population with gallstones
  • 20% >65 years of age
  • Female > male (2 to 3:1)

Etiology and Pathophysiology

  • Gallstone formation is a complex process mediated by genetic, metabolic, immune, and environmental factors. Gallbladder sludge (a mixture of cholesterol crystals, calcium bilirubinate granules, and mucin gel matrix) serves as the nidus for gallstone formation.
  • Bile supersaturated with cholesterol (cholesterol stones) precipitates as microcrystals that aggregate and expand. Stone formation is enhanced by biliary stasis or impaired gallbladder motility.
  • Decrease in bile phospholipid (lecithin) or decreased bile salt secretion
  • Excess unconjugated bilirubin in patients with hemolytic diseases; passage of excess bile salt into the colon with subsequent absorption of excess unconjugated bilirubin in patients with inflammatory bowel disease (IBD) or after distal ileal resection (black or pigment stones)
  • Hydrolysis of conjugated bilirubin or phospholipid by bacteria in patients with biliary tract infection or stricture (brown stones or primary bile duct stones; rare in the Western world and common in Asia)

Risk Factors

  • Age peaks in patients 60 to 80 years of age.
  • Female gender, pregnancy, multiparity, obesity, and metabolic syndrome
  • Caucasian, Hispanic, or Native American descent
  • High-fat diet rich in cholesterol
  • Cholestasis or impaired gallbladder motility in association with prolonged fasting, long-term total parenteral nutrition (TPN), following vagotomy, long-term somatostatin therapy, and rapid weight loss
  • Hereditary (p.D19H variant for the hepatic canalicular cholesterol transporter ABCG5/ABG8)
  • Short gut syndrome, terminal ileal resection, IBD
  • Hemolytic disorders (hereditary spherocytosis, sickle cell anemia, etc.), cirrhosis (black/pigment stones)
  • Medications (birth control pills, estrogen replacement therapy at high doses, and long-term corticosteroid or cytostatic therapy)
  • Viral hepatitis, biliary tract infection, and stricture (promotes intraductal formation of pigment stones)

General Prevention

  • Ursodiol (Actigall) taken during rapid weight loss prevents gallstone formation.
  • Regular exercise and dietary modification may reduce the incidence of gallstone formation.
  • Lipid-lowering drugs (statins) may prevent cholesterol stone formation by reducing bile cholesterol saturation.

Commonly Associated Conditions

90% of people with gallbladder carcinoma have gallstones and chronic cholecystitis.

Diagnosis

History

  • Mostly asymptomatic (80%): 2% become symptomatic each year. Over their lifetime, <50% of patients with gallstones develop symptoms.
  • Episodic right upper quadrant or epigastric pain lasting >15 minutes and sometimes radiating to the back (biliary colic—due to transient cystic duct obstruction)
  • Pain is usually postprandial.
  • Pain sometimes awakens patients from sleep.
  • Most patients develop recurrent symptoms after a first episode of biliary colic.
  • Other symptoms include nausea, vomiting, indigestion or bloating sensation, and fatty food intolerance.

Physical Exam

  • Physical exam is usually normal in patients with cholelithiasis in the absence of an acute attack.
  • Epigastric and/or right upper quadrant tenderness (Murphy sign) is a traditional physical finding associated with acute cholecystitis. Murphy sign has limited sensitivity and specificity.
  • Charcot triad: fever, jaundice, right upper quadrant pain
  • Reynolds pentad: fever, jaundice, right upper quadrant pain, hemodynamic instability, mental status changes; classically associated with ascending cholangitis
  • Flank and periumbilical ecchymoses (Cullen sign and Grey Turner sign) in patients with acute hemorrhagic pancreatitis
  • Courvoisier sign: palpable mass in the right upper quadrant in patient with obstructive jaundice most commonly due to malignant tumors within the biliary tree or pancreas

Differential Diagnosis

  • Peptic ulcer diseases and gastritis
  • Hepatitis
  • Pancreatitis
  • Cholangitis
  • Gallbladder cancer
  • Gallbladder polyps
  • Acalculous cholecystitis
  • Biliary dyskinesia
  • Choledocholithiasis

Diagnostic Tests & Interpretation

No laboratory study is specific for cholelithiasis.

Initial Tests (lab, imaging)
  • Leukocytosis and elevated C-reactive protein level are associated with acute calculus cholecystitis.
  • Ultrasound (US) is the preferred imaging modality. US detects gallstones in 97–98% of patients.
  • Thickening of the gallbladder wall (≥5 mm), pericholecystic fluid, and direct tenderness when the probe is pushed against the gallbladder (sonographic Murphy sign) are associated with acute cholecystitis.
  • CT scan has no advantage over US except for detecting distal common bile duct (CBD) stones.
  • MR cholangiopancreatography (MRCP) is reserved for cases of suspected CBD stones. However, MRCP has no therapeutic value, and preoperative MRCP is not more cost-effective than initial cholecystectomy with cholangiography in the diagnosis of patients with suspected CBD stones.
  • Endoscopic US is as sensitive as endoscopic retrograde cholangiopancreatography (ERCP) for detection of CBD stones in patients with gallstone pancreatitis (GP).
  • Hepatobiliary iminodiacetic acid (HIDA) scan is useful in diagnosing acute cholecystitis secondary to cystic duct obstruction. It is also useful in differentiating acalculous cholecystitis from other causes of abdominal pain. False-positive tests can result from a fasting state, insufficient resistance of the sphincter of Oddi, and gallbladder agenesis.
  • Cholecystokinin (CCK)-HIDA is specifically used to diagnose gallbladder dysmotility (biliary dyskinesia).
  • 10–30% of gallstones are radiopaque calcium or pigment-containing gallstones (visible on plain x-ray). A “porcelain gallbladder” is a calcified gallbladder (also visible by x-ray) that is associated with chronic cholecystitis and gallbladder cancer.
Test Interpretation
  • Pure cholesterol stones are white or slightly yellow.
  • Pigment stones may be black or brown. Black stones contain polymerized calcium bilirubinate, most often secondary to cirrhosis or hemolysis; these almost always form within the gallbladder.
  • Brown stones are associated with biliary tract infection, caused by bile stasis, and as such may form either in the bile ducts or gallbladder.

Treatment

General Measures

  • Treat symptomatic cholelithiasis.
  • Conservative therapy is preferred during pregnancy; surgery in the 2nd trimester if necessary
  • Prophylactic cholecystectomy for patients with calcified (porcelain) gallbladder (risk for gallbladder cancer), patients with large stones (≥3 cm), patients with sickle cell disease, patients planning an organ transplant, and patients with recurrent pancreatitis due to microlithiasis
  • In morbidly obese patients, cholecystectomy may be performed in combination with bariatric procedures to reduce subsequent stone-related comorbidities.
  • Prophylactic cholecystectomy is recommended for gallstones discovered incidentally during open abdominal surgery.

Geriatric Considerations
Gallstones are more common in the elderly. Age alone should not alter the therapeutic plan.

Medication

First Line
  • Analgesics for pain relief
    • NSAIDs are the first-choice treatment for pain control which is equivalent to opioid therapy.
    • Opioids are an option for patients who cannot tolerate or fail to respond to NSAIDs.
  • Antibiotics for patients with acute cholecystitis
  • Prophylactic antibiotics in low-risk patients do not prevent infections during laparoscopic cholecystectomy (LC) (1)[A].

Issues For Referral

Patients with retained or recurrent bile duct stones following cholecystectomy should be referred for ERCP.

Surgery/Other Procedures

  • Surgery should be considered for patients who have symptomatic cholelithiasis or gallstone-related complications (e.g., cholecystitis) or in asymptomatic patients with immune suppression, calcified gallbladder, or family history of gallbladder cancer.
  • Open and LC have similar mortality and complication rates. LC offers less pain and quicker recovery and is the current gold-standard treatment.
  • In well-selected patients, single-incision LC (SILC) and robotic LC are treatments for symptomatic cholelithiasis. SILC has not been shown to be superior to conventional multiport LC in terms of pain and risk of complications (2)[A]. Natural orifice transluminal endoscopic surgery (NOTES) is investigational. Surgery-related complications include CBD injury (0.2%), right hepatic duct/artery injury, retained stones, duct leak, biloma formation, and bile duct stricture. Bile spillage during LC has been shown to be a risk factor for surgical site infection.
    • Conversion to open procedure is based on clinical judgment. Male gender, previous upper abdominal surgery, thickened gallbladder wall, and acute cholecystitis increase the likelihood of need to convert to an open procedure.
    • In 10–15% of patients with symptomatic cholelithiasis, CBD stones are detected by intraoperative cholangiogram (IOC). CBD stone(s) can be removed by laparoscopic CBD exploration or postoperative ERCP.
    • IOC helps delineate bile duct anatomy when dissection is difficult. Routine use of IOC is controversial and may be associated with decreased incidence and severity of bile duct injury.
  • Early LC (<24 hours after diagnosis of biliary colic) decreases hospital stay and operating time (3)[A].
  • For patients with acute cholecystitis, early LC (<7 days of clinical presentation) is safe and may shorten the total hospital stay versus delayed LC (>6 weeks after index admission with acute cholecystitis) (4)[A].
  • Percutaneous cholecystostomy (PC) is used for high-risk patients with cholecystitis or gallbladder empyema. Interval cholecystectomy is recommended.
  • Symptomatic patients who are not candidates for surgery or those who have small gallstones (5 mm or smaller) in a functioning gallbladder with a patent cystic duct are candidates for oral dissolution therapy (ursodiol [Actigall]). The recurrence rate is >50% once medication is discontinued.
  • Extracorporeal shock wave lithotripsy is a noninvasive therapeutic alternative for symptomatic patients who are not candidates for surgery. It helps break down large bile duct stones before ERCP. Complications include biliary pancreatitis, hepatic hematoma, incomplete ductal stone clearance, and recurrence.

Inpatient Considerations

For patients with symptomatic cholelithiasis, LC is typically an outpatient procedure. For patients with complications (i.e., cholecystitis, cholangitis, pancreatitis), inpatient care is necessary.

  • Acute phase: NPO, IV fluids, and antibiotics
  • Adequate pain control with narcotics and/or NSAIDs

Ongoing Care

Follow-up Recommendations

Patient Monitoring
  • Follow for signs of symptomatic cholelithiasis.
  • Follow patients on oral dissolution agents with serial liver enzymes, serum cholesterol, and imaging.

Diet

A low-fat diet may help.

Patient Education

  • Change in lifestyle (e.g., regular exercise) and dietary modification (low-fat diet and reduction of total caloric intake) reduce gallstone-related hospitalizations.
  • Patients with asymptomatic gallstones should be educated about the typical symptoms of biliary colic and gallstone-related complications.

Prognosis

  • <50% of patients with gallstones become symptomatic.
  • Cholecystectomy-related mortality is <0.5% in elective cases and 3–5% in emergency cases; morbidity is <10% in elective cases and 30–40% in emergency cases.
  • ~10–15% of patients have associated choledocholithiasis.
  • After cholecystectomy, stones may recur within the biliary tree in patients with associated risk factors.

Complications

  • Acute cholecystitis (90–95% secondary to gallstones)
  • GP; ERCP ± sphincterotomy of no clear benefit in patients with mild GP but reduces complications in those with severe GP (5)[A]
  • CBD stones with obstructive jaundice and acute cholangitis. In patients undergoing ERCP for CBD stones, early LC reduces the risk of recurrent biliary events (6)[B].
  • Biliary-enteric fistula and gallstone ileus
  • Bouveret syndrome is a variant of gallstone ileus where the gallstone lodges in the duodenum or pylorus causing a gastric outlet obstruction.
  • Gallbladder cancer
  • Mirizzi syndrome (extrinsic bile duct obstruction caused by gallstones lodged in gallbladder or cystic duct)

Additional Reading

  • Brown LM, Rogers SJ, Cello JP, et al. Cost-effective treatment of patients with symptomatic cholelithiasis and possible common bile duct stones. J Am Coll Surg. 2011;212(6):1049.e1–1060.e7. [PMID:21444220]
  • Keus F, Gooszen HG, van Laarhoven CJ. Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews. Cochrane Database Syst Rev. 2010;(1):CD008318. [PMID:20091665]
  • Peponis T, Eskesen TG, Mesar T, et al. Bile spillage as a risk factor for surgical site infection after laparoscopic cholecystectomy: a prospective study of 1,001 patients. J Am Coll Surg. 2018;226(6):1030–1035. [PMID:29501782]

See Also

Cholangitis, Acute ; Choledocholithiasis

Codes

ICD-10

  • K80.00 Calculus of gallbladder w acute cholecyst w/o obstruction
  • K80.01 Calculus of gallbladder w acute cholecystitis w obstruction
  • K80.18 Calculus of gallbladder w oth cholecystitis w/o obstruction
  • K80.19 Calculus of gallbladder w oth cholecystitis with obstruction
  • K80.20 Calculus of gallbladder w/o cholecystitis w/o obstruction
  • K80.21 Calculus of gallbladder w/o cholecystitis with obstruction

ICD-9

  • 574.00 Calculus of gallbladder with acute cholecystitis, without mention of obstruction
  • 574.01 Calculus of gallbladder with acute cholecystitis, with obstruction
  • 574.10 Calculus of gallbladder with other cholecystitis, without mention of obstruction
  • 574.11 Calculus of gallbladder with other cholecystitis, with obstruction
  • 574.20 Calculus of gallbladder without mention of cholecystitis, without mention of obstruction
  • 574.21 Calculus of gallbladder without mention of cholecystitis, with obstruction

SNOMED

  • 235919008 gallbladder calculus (disorder)
  • 25924004 Calculus of gallbladder with cholecystitis (disorder)
  • 266474003 calculus in biliary tract (disorder)
  • 29484002 Cholelithiasis AND cholecystitis without obstruction
  • 50450007 Cholelithiasis AND cholecystitis with obstruction
  • 59771005 Calculus of gallbladder with acute cholecystitis (disorder)
  • 699050007 Calculus of gallbladder with acute and chronic cholecystitis (disorder)
  • 77528005 cholelithiasis with obstruction (disorder)

Clinical Pearls

  • Most patients with gallstones are asymptomatic.
  • Transabdominal US is the imaging modality of choice for the diagnosis of cholelithiasis (sensitivity, 97%; specificity, 95%).
  • LC is the preferred surgical procedure for symptomatic cholelithiasis.
  • Acute acalculous cholecystitis is associated with bile stasis and gallbladder ischemia.
  • Prophylactic cholecystectomy is not indicated in patients with asymptomatic gallstones.

Authors


Hongyi Cui, MD, PhD

Bibliography

  1. Sanabria A, Dominguez LC, Valdivieso E, et al. Antibiotic prophylaxis for patients undergoing elective laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2010;(12):CD005265. [PMID:21154360]
  2. Gurusamy KS, Vaughan J, Rossi M, et al. Fewer-than-four ports versus four ports for laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2014;(2):CD007109. [PMID:24558020]
  3. Gurusamy KS, Koti R, Fusai G, et al. Early versus delayed laparoscopic cholecystectomy for uncomplicated biliary colic. Cochrane Database Syst Rev. 2013;(6):CD007196. [PMID:23813478]
  4. Gurusamy KS, Davidson C, Gluud C, et al. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev. 2013;(6):CD005440. [PMID:23813477]
  5. Burstow MJ, Yunus RM, Hossain MB, et al. Meta-analysis of early endoscopic retrograde cholangiopancreatography (ERCP) ± endoscopic sphincterotomy (ES) versus conservative management for gallstone pancreatitis (GSP). Surg Laparosc Endosc Percutan Tech. 2015;25(3):185–203.  [PMID:25799261]
  6. Huang RJ, Barakat MT, Girotra M, et al. Practice patterns for cholecystectomy after endoscopic retrograde cholangiopancreatography for patients with choledocholithiasis. Gastroenterology. 2017;153(3):762.e2–771.e2.  [PMID:28583822]


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