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Tuesday, August 12, 2025

Gallstones


Definition

Gallstones, or cholelithiasis, are solid crystalline concretions formed within the gallbladder from the precipitation of bile components such as cholesterol, bile pigments, and calcium salts. They may remain asymptomatic or cause biliary colic, cholecystitis, and other complications.

Epidemiology

  • Prevalence: 10–15% of adults in developed countries

  • More common in women, especially between ages 40–60

  • Higher prevalence in certain ethnic groups (e.g., Native Americans, Hispanics)

  • Increased incidence with advancing age

Risk Factors

Mnemonic – “5 F’s”: Female, Forty, Fertile, Fat, Fair

  • Sex: Women > Men (estrogen increases cholesterol secretion into bile)

  • Age: Risk rises after age 40

  • Obesity and rapid weight loss

  • Pregnancy and multiparity

  • Hormone therapy (estrogen, oral contraceptives)

  • Family history of gallstones

  • Ethnicity: Native American, Hispanic

  • Medical conditions: diabetes mellitus, cirrhosis, hemolytic anaemias, Crohn’s disease, total parenteral nutrition

  • Dietary factors: high-calorie, high-cholesterol, low-fibre diet

Types of Gallstones

  1. Cholesterol stones (80% in Western countries)

    • Form due to supersaturation of cholesterol in bile

  2. Pigment stones

    • Black pigment stones: associated with chronic haemolysis (e.g., sickle cell anaemia)

    • Brown pigment stones: associated with biliary infection and stasis

Pathophysiology

Gallstones form when bile becomes supersaturated with cholesterol or bilirubin, leading to crystal precipitation. Gallbladder hypomotility and mucin hypersecretion promote stone growth.

Clinical Presentation

Asymptomatic:

  • Most cases discovered incidentally on imaging

Symptomatic (biliary colic):

  • Sudden, steady pain in the right upper quadrant (RUQ) or epigastrium, lasting 30 minutes to several hours

  • Pain may radiate to the right shoulder or back

  • Often triggered by fatty meals

  • Associated nausea, vomiting

Complications

  • Acute cholecystitis: Persistent cystic duct obstruction with inflammation

  • Choledocholithiasis: Stones in the common bile duct

  • Cholangitis: Biliary tract infection, potentially life-threatening

  • Gallstone pancreatitis

  • Gallbladder carcinoma (rare, long-standing stones)

Diagnosis

History and examination – episodic RUQ pain, Murphy’s sign (in acute cholecystitis)

Investigations:

  • Ultrasound: First-line; detects stones and gallbladder wall thickening

  • Liver function tests: Elevated bilirubin, alkaline phosphatase in ductal obstruction

  • Endoscopic ultrasound (EUS): High sensitivity for small stones

  • MRCP (Magnetic Resonance Cholangiopancreatography): For suspected common bile duct stones

  • ERCP (Endoscopic Retrograde Cholangiopancreatography): Diagnostic and therapeutic for choledocholithiasis

Management

1. Asymptomatic Gallstones

  • No treatment unless high risk of complications (e.g., porcelain gallbladder, haemolytic anaemia)

  • Lifestyle modification: healthy weight, low-cholesterol diet

2. Symptomatic Gallstones (Biliary Colic)

Definitive treatment:

  • Elective laparoscopic cholecystectomy – gold standard, prevents recurrence

Medical management (for patients unfit for surgery):

  • Ursodeoxycholic acid: 8–10 mg/kg/day orally in 2–3 divided doses for 6–12 months; dissolves cholesterol stones in selected patients (small, non-calcified stones, functioning gallbladder)

Analgesia during acute biliary colic:

  • NSAIDs (first-line): Diclofenac 75 mg intramuscularly once, or Ibuprofen 400–600 mg orally every 6–8 hours

  • Opioids if severe pain: Morphine 2.5–5 mg IV every 4 hours as needed (use cautiously; may cause sphincter of Oddi spasm)

  • Antiemetics: Metoclopramide 10 mg orally/IV every 8 hours or Ondansetron 4–8 mg orally/IV every 8 hours

3. Complicated Gallstones

Acute cholecystitis:

  • Hospital admission

  • Nil by mouth, IV fluids

  • Analgesia: NSAIDs or opioids as above

  • Antibiotics (cover Gram-negative and anaerobes):

    • Ceftriaxone 1–2 g IV once daily + Metronidazole 500 mg IV every 8 hours

    • Alternative: Piperacillin-tazobactam 4.5 g IV every 6–8 hours

  • Early laparoscopic cholecystectomy within 72 hours

Choledocholithiasis:

  • ERCP to remove stones, followed by cholecystectomy

Cholangitis:

  • Emergency management with IV antibiotics (e.g., Piperacillin-tazobactam 4.5 g IV q6–8h)

  • Urgent biliary decompression (ERCP)

Gallstone pancreatitis:

  • Supportive care (IV fluids, analgesia)

  • ERCP if biliary obstruction persists

  • Cholecystectomy after recovery

Lifestyle and Prevention

  • Maintain healthy body weight

  • Avoid rapid weight loss diets

  • Regular physical activity

  • Balanced diet with adequate fibre, low in saturated fats

Prognosis

  • Asymptomatic gallstones may remain silent for years

  • Symptomatic stones have a high recurrence rate without surgery

  • Early intervention reduces risk of life-threatening complications




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