Gall stones

Hepato-Pancreatico-Biliary

Clinicals - History

Fact Explanation
Incidental finding of gall stones About 90% of gallstones cause no symptoms. They may be found incidentally during a abdominal ultra sound scan due to another reason Incidental finding of gall stones
About 90% of gallstones cause no symptoms. They may be found incidentally during a abdominal ultra sound scan due to another reason
Abdominal pain Occur due to the complications of gall stones such as biliary colic, acute/chronic cholecystitis, cholangitis and pancreatitis due to inflammation and the stasis of bile flow Abdominal pain
Occur due to the complications of gall stones such as biliary colic, acute/chronic cholecystitis, cholangitis and pancreatitis due to inflammation and the stasis of bile flow
Fever Occur due to acute/chronic cholecystitis, cholangitis and pancreatitis due to inflammation.
Patients with acute cholecystitis may have fever and chills, which usually do not occur with uncomplicated biliary colic.
Fever
Occur due to acute/chronic cholecystitis, cholangitis and pancreatitis due to inflammation.
Patients with acute cholecystitis may have fever and chills, which usually do not occur with uncomplicated biliary colic.
Yellow discolouration of eyes, dark urine, pale stools Occurs due to obstruction to the bile flow caused by Choledocholithiasis Yellow discolouration of eyes, dark urine, pale stools
Occurs due to obstruction to the bile flow caused by Choledocholithiasis
Advanced age By age 75, approximately 35% of women and 20% of men have developed gallstones. Although it is a common disease, most cases are asymptomatic and the patient remains unaware of its presence Advanced age
By age 75, approximately 35% of women and 20% of men have developed gallstones. Although it is a common disease, most cases are asymptomatic and the patient remains unaware of its presence
Obesity Being overweight is a significant risk factor for gallstones. In such cases, the liver over-produces cholesterol, which is delivered into the bile and causes it to become supersaturated Obesity
Being overweight is a significant risk factor for gallstones. In such cases, the liver over-produces cholesterol, which is delivered into the bile and causes it to become supersaturated
Hormone replacement therapy Several large studies have shown that the use of hormone replacement therapy (HRT) doubles or triples the risk for gallstones, hospitalization for gallbladder disease, or gallbladder surgery. Estrogen raises triglycerides, a fatty substance that increases the risk for cholesterol stones Hormone replacement therapy
Several large studies have shown that the use of hormone replacement therapy (HRT) doubles or triples the risk for gallstones, hospitalization for gallbladder disease, or gallbladder surgery. Estrogen raises triglycerides, a fatty substance that increases the risk for cholesterol stones
Pregnancy Pregnancy increases the risk for gallstones, and pregnant women with stones are more likely to develop symptoms than women who are not pregnant. Surgery should be delayed until after delivery if possible. In fact, gallstones may disappear after delivery. Pregnancy
Pregnancy increases the risk for gallstones, and pregnant women with stones are more likely to develop symptoms than women who are not pregnant. Surgery should be delayed until after delivery if possible. In fact, gallstones may disappear after delivery.
Family history of gall stones Having a family member or close relative with gallstones may increase the risk. Up to 33% of cases of painful gallstones may be related to genetic factors. Family history of gall stones
Having a family member or close relative with gallstones may increase the risk. Up to 33% of cases of painful gallstones may be related to genetic factors.
Drugs Fibric acid derivatives (or fibrates), contraceptive steroids, postmenopausal estrogens, progesterone, octreotide, ceftriaxone increase the risk of gall stone formation Drugs
Fibric acid derivatives (or fibrates), contraceptive steroids, postmenopausal estrogens, progesterone, octreotide, ceftriaxone increase the risk of gall stone formation
Metabolic syndrome Research suggests that metabolic syndrome is a risk factor for gallstones Metabolic syndrome
Research suggests that metabolic syndrome is a risk factor for gallstones
Gender - female women are probably at increased risk because estrogen stimulates the liver to remove more cholesterol from blood and divert it into the bile Gender - female
women are probably at increased risk because estrogen stimulates the liver to remove more cholesterol from blood and divert it into the bile
Hemolytic anemia Increased risk of pigment stones due to excess break down of red blood cells (excess bilirubin and hemosiderin) Hemolytic anemia
Increased risk of pigment stones due to excess break down of red blood cells (excess bilirubin and hemosiderin)
Gastrointestinal tract microorganisms - common bile duct stone Gastrointestinal tract microorganisms such as Escherichia coli, Klebsiella, Proteus, Bacteroides, and Clostridium have been isolated from the bile of patients with primary duct stones. In addition, bacterial cytoskeletons are invariably seen in primary duct stones under electronic microscope. These bacteria may have a contributory role by producing enzymes that catalyze deconjugation of bilirubin and lysis of phospholipids, which in turn promote the precipitation of calcium bilirubinate and initiate stone formation Gastrointestinal tract microorganisms - common bile duct stone
Gastrointestinal tract microorganisms such as Escherichia coli, Klebsiella, Proteus, Bacteroides, and Clostridium have been isolated from the bile of patients with primary duct stones. In addition, bacterial cytoskeletons are invariably seen in primary duct stones under electronic microscope. These bacteria may have a contributory role by producing enzymes that catalyze deconjugation of bilirubin and lysis of phospholipids, which in turn promote the precipitation of calcium bilirubinate and initiate stone formation
Ethnicity Because gallstones are related to diet, particularly fat intake, the incidence of gallstones varies widely among nations and regions. For example, Hispanics and Northern Europeans have a higher risk for gallstones than do people of Asian and African descent. People of Asian descent who develop gallstones are most likely to have the brown pigment type Ethnicity
Because gallstones are related to diet, particularly fat intake, the incidence of gallstones varies widely among nations and regions. For example, Hispanics and Northern Europeans have a higher risk for gallstones than do people of Asian and African descent. People of Asian descent who develop gallstones are most likely to have the brown pigment type

Clinicals - Examination

Fact Explanation
Abdominal tenderness Occur due to the complications of gall stones such as biliary colic, acute/chronic cholecystitis, cholangitis and pancreatitis due to inflammation and the stasis of bile flow
In acute/ chronic cholecystitis, cholangitis, tenderness is present mainly in right hypochondriac area and tenderness is present mainly in epigastric area in biliary colic and pancreatitis.But this may vary
Abdominal tenderness
Occur due to the complications of gall stones such as biliary colic, acute/chronic cholecystitis, cholangitis and pancreatitis due to inflammation and the stasis of bile flow
In acute/ chronic cholecystitis, cholangitis, tenderness is present mainly in right hypochondriac area and tenderness is present mainly in epigastric area in biliary colic and pancreatitis.But this may vary
Abdominal mass Gall bladder may be palpable as a right hypochondriacal mass in acute cholecystitis Abdominal mass
Gall bladder may be palpable as a right hypochondriacal mass in acute cholecystitis
Boa's sign The pain may be referred pain that is felt in the right scapula rather than the right upper quadrant or epigastric region in acute cholecystitis Boa's sign
The pain may be referred pain that is felt in the right scapula rather than the right upper quadrant or epigastric region in acute cholecystitis
Murphy sign In acute cholecystitis.
It is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive
Murphy sign
In acute cholecystitis.
It is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive
Febrile Occur due to acute/chronic cholecystitis, cholangitis and pancreatitis due to inflammation.
Patients with acute cholecystitis may have fever and chills
Febrile
Occur due to acute/chronic cholecystitis, cholangitis and pancreatitis due to inflammation.
Patients with acute cholecystitis may have fever and chills
Jaundice Occurs due to obstruction to the bile flow caused by Choledocholithiasis Jaundice
Occurs due to obstruction to the bile flow caused by Choledocholithiasis

Investigations - Diagnosis

Fact Explanation
Ultra sound scan abdomen To detect gall stones and acute cholecystitis.

Ultrasonography should be a routine examination for the confirmation or exclusion of gallstone disease. Ultrasonography provides more than 95 percent sensitivity and specificity for the diagnosis of gallstones greater than 2 mm in diameter.

Upon ultrasound a wall thickening >4 mm of the gallbladder, a sonographic Murphy sign and pericholecystic fluid are suggestive of acute cholecystitis.

Ultrasonography is less sensitive for the diagnosis of choledocholithiasis and may document only one half of common bile duct stones.
Ultra sound scan abdomen
To detect gall stones and acute cholecystitis.

Ultrasonography should be a routine examination for the confirmation or exclusion of gallstone disease. Ultrasonography provides more than 95 percent sensitivity and specificity for the diagnosis of gallstones greater than 2 mm in diameter.

Upon ultrasound a wall thickening >4 mm of the gallbladder, a sonographic Murphy sign and pericholecystic fluid are suggestive of acute cholecystitis.

Ultrasonography is less sensitive for the diagnosis of choledocholithiasis and may document only one half of common bile duct stones.
Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic retrograde cholangiopancreatography (ERCP) is the best method for determining a diagnosis of choledocholithiasis. ERCP provides diagnostic and therapeutic options, and has a sensitivity and specificity of 95 percent for the detection of common bile duct stones. Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopic retrograde cholangiopancreatography (ERCP) is the best method for determining a diagnosis of choledocholithiasis. ERCP provides diagnostic and therapeutic options, and has a sensitivity and specificity of 95 percent for the detection of common bile duct stones.
computed tomographic (CT) and magnetic resonance imaging (MRI) The latest computer technology, processing computed tomographic (CT) and magnetic resonance imaging (MRI) data into a three-dimensional image of the bile duct, is now comparable to the ERCP in terms of diagnostic accuracy.

Wall thickening >4 mm, subserosal edema without ascites, intramural gas, pericholecystic fluid, and sloughed mucosa.are the findings suggestive of cholecystitis.
computed tomographic (CT) and magnetic resonance imaging (MRI)
The latest computer technology, processing computed tomographic (CT) and magnetic resonance imaging (MRI) data into a three-dimensional image of the bile duct, is now comparable to the ERCP in terms of diagnostic accuracy.

Wall thickening >4 mm, subserosal edema without ascites, intramural gas, pericholecystic fluid, and sloughed mucosa.are the findings suggestive of cholecystitis.
Hepatobiliary scintigraphy Hepatobiliary scintigraphy can confirm or exclude the diagnosis of acute cholecystitis with a high degree of sensitivity and specificity. After a two- to four-hour fast, the patient is given an intravenous injection of a technetium-99m–labeled iminodiacetic acid derivative (IDA agent) that is excreted into the bile ducts and sequentially imaged under a gamma camera. Hepatobiliary scintigraphy
Hepatobiliary scintigraphy can confirm or exclude the diagnosis of acute cholecystitis with a high degree of sensitivity and specificity. After a two- to four-hour fast, the patient is given an intravenous injection of a technetium-99m–labeled iminodiacetic acid derivative (IDA agent) that is excreted into the bile ducts and sequentially imaged under a gamma camera.

Investigations - Management

Fact Explanation
Fasting blood sugar Important to identify diabetes as gallbladder disease may progress more rapidly in patients with diabetes, who tend to have worse infections. Fasting blood sugar
Important to identify diabetes as gallbladder disease may progress more rapidly in patients with diabetes, who tend to have worse infections.
Full blood count High white blood cell count due to on going infection. ( In acute cholecystitis, leukocytosis with a “left shift” is usually observed) Full blood count
High white blood cell count due to on going infection. ( In acute cholecystitis, leukocytosis with a “left shift” is usually observed)
Screen for cholecystitis as a complication Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) bilirubin levels can be measured as they may be seen elevated with cholecystitis or common bile duct obstruction. Screen for cholecystitis as a complication
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) bilirubin levels can be measured as they may be seen elevated with cholecystitis or common bile duct obstruction.
Screen for pancreatitis as a complication The most reliable indicator of gallstones as the cause of acute pancreatitis is an elevation of alanine aminotransferase levels greater than 2.5 times above normal.
To evaluate the presence of pancreatitis Amylase/lipase assays are used.
Screen for pancreatitis as a complication
The most reliable indicator of gallstones as the cause of acute pancreatitis is an elevation of alanine aminotransferase levels greater than 2.5 times above normal.
To evaluate the presence of pancreatitis Amylase/lipase assays are used.

Management - Supportive

Fact Explanation
Asymptomatic gall stones Adult patients with silent or incidental gallstones should be observed and managed expectantly, including patients with diabetes. In diabetic patients, the natural history of gallstones is generally benign, and there is low risk of a major complication Asymptomatic gall stones
Adult patients with silent or incidental gallstones should be observed and managed expectantly, including patients with diabetes. In diabetic patients, the natural history of gallstones is generally benign, and there is low risk of a major complication
Antibiotics Antibiotics are given to treat the ongoing infection Antibiotics
Antibiotics are given to treat the ongoing infection
Acute cholecystitis initial treatment Initial treatment will usually involve:
fasting (not eating or drinking) to take the strain off the gallbladder,
receiving fluids through a drip directly into a vein (intravenously) to prevent dehydration,
taking medication to relieve the pain
Acute cholecystitis initial treatment
Initial treatment will usually involve:
fasting (not eating or drinking) to take the strain off the gallbladder,
receiving fluids through a drip directly into a vein (intravenously) to prevent dehydration,
taking medication to relieve the pain
Biliary colic initial treatment Correcting electrolyte and fluid imbalance that may occur with vomiting.
Antiemetics are used to treat the nausea. Pain is usually corrected with anti-inflammatories, NSAIDs
Biliary colic initial treatment
Correcting electrolyte and fluid imbalance that may occur with vomiting.
Antiemetics are used to treat the nausea. Pain is usually corrected with anti-inflammatories, NSAIDs

Management - Specific

Fact Explanation
Nonoperative Therapies for Symptomatic Gallstones Oral bile acid dissolution: ursodeoxycholic acid, at 8 to 10 mg per kg per day - Stone clearance: 30 to 90 percent with zero percent mortality.

Contact solvents: methyl tert-butyl ether/ n-propyl acetate -
Stone clearance: 50 to 90 percent

Extracorporeal shock-wave lithotripsy: electrohydraulic/electromagnetic -
Stone clearance: 70 to 90 percent with < 0.1 percent mortality
Nonoperative Therapies for Symptomatic Gallstones
Oral bile acid dissolution: ursodeoxycholic acid, at 8 to 10 mg per kg per day - Stone clearance: 30 to 90 percent with zero percent mortality.

Contact solvents: methyl tert-butyl ether/ n-propyl acetate -
Stone clearance: 50 to 90 percent

Extracorporeal shock-wave lithotripsy: electrohydraulic/electromagnetic -
Stone clearance: 70 to 90 percent with < 0.1 percent mortality
Acute cholecystitis - laparoscopic cholecystectomy Most physicians agree that early laparoscopic cholecystectomy (within 24 to 48 hours) is indicated once the diagnosis of acute cholecystitis is secure and the patient is hemodynamically stable. Use of this surgical technique is supported by large randomized trials conclusively demonstrating its clinical superiority over open cholecystectomy.
The potential advantages of laparoscopic cholecystectomy include a marked reduction in pain during postoperative period, a shorter duration of hospital stay and a more rapid resumption to work and usual activities.
Acute cholecystitis - laparoscopic cholecystectomy
Most physicians agree that early laparoscopic cholecystectomy (within 24 to 48 hours) is indicated once the diagnosis of acute cholecystitis is secure and the patient is hemodynamically stable. Use of this surgical technique is supported by large randomized trials conclusively demonstrating its clinical superiority over open cholecystectomy.
The potential advantages of laparoscopic cholecystectomy include a marked reduction in pain during postoperative period, a shorter duration of hospital stay and a more rapid resumption to work and usual activities.
Choledocholithiasis - Endoscopic retrograde cholangiopancreatography (ERCP) with possible sphincterotomy and stone extraction When a patient with known gallbladder stones has concomitant choledocholithiasis, the management varies with the severity of clinical features. In general, the presence of obstructive cholangitis or jaundice with a dilated common bile duct detected by ultrasonography should lead promptly to a preoperative ERCP with possible sphincterotomy and stone extraction. Once the bile duct has been cleared by ERCP, the patient can undergo a routine laparoscopic cholecystectomy within one or two days. Choledocholithiasis - Endoscopic retrograde cholangiopancreatography (ERCP) with possible sphincterotomy and stone extraction
When a patient with known gallbladder stones has concomitant choledocholithiasis, the management varies with the severity of clinical features. In general, the presence of obstructive cholangitis or jaundice with a dilated common bile duct detected by ultrasonography should lead promptly to a preoperative ERCP with possible sphincterotomy and stone extraction. Once the bile duct has been cleared by ERCP, the patient can undergo a routine laparoscopic cholecystectomy within one or two days.

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. AHMED A, CHEUNG RC, KEEFFE EB. Management of gallstones and their complications. Am Fam Physician [online] 2000 Mar 15, 61(6):1673-80, 1687-8 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10750875
  2. Guidelines for the Treatment of Gallstones. Ann Intern Med [online] 1993 October [viewed 26 August 2014] Available from: doi:10.7326/0003-4819-119-7_Part_1-199310010-00011
  3. HIROTA M, TAKADA T, KAWARADA Y, NIMURA Y, MIURA F, HIRATA K, MAYUMI T, YOSHIDA M, STRASBERG S, PITT H, GADACZ TR, DE SANTIBANES E, GOUMA DJ, SOLOMKIN JS, BELGHITI J, NEUHAUS H, BüCHLER MW, FAN ST, KER CG, PADBURY RT, LIAU KH, HILVANO SC, BELLI G, WINDSOR JA, DERVENIS C. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines J Hepatobiliary Pancreat Surg [online] 2007 Jan, 14(1):78-82 [viewed 26 August 2014] Available from: doi:10.1007/s00534-006-1159-4