What is cholelithiasis? Causes, clinical features and management of cholelithiasis

Gallstone disease

Gallbladder stone

What is cholelithiasis?

Definition:- 

Gallbladder stone is also called cholelithiasis.

 Cholelithiasis is a disease in which stones are formed in the gall bladder lumen. Sometimes the stone is present in the common bile duct and it is called choledocholithiasis.

Gallbladder stones may be solitary or multiple.

    Gallstone disease is a new nomenclature for the gallbladder diseases associated with the complication of gallbladder stone-like acute cholecystitis with stone. 

    Previously it was called calculus cholecystitis.

    Acute cholecystitis without calculus in the gallbladder lumen is called acalculous cholecystitis.

Incidence:-

Common in females than men.

Fat, Fertile, Flatulent, Female of Forty ie 5F are more commonly prone to develop gallstones.

What are the risk factors of cholelithiasis?

The risk factors are following:

• 4F

                Female
                Fatty
                Forty
                Fertile

• Oral contraceptive pills ( OCP )
• Hormone replacement therapy
• Family history
• Rapid weight loss
• Diet - 

                High-calorie diet.
                Refined carbohydrates in the diet.
                Low fibers diet.

• Chronic liver disease – cirrhosis
• Infection –Cholangitis, Cholecystitis
• Hemolytic disease – sickle cell disease, hereditary spherocytosis

What is the Pathophysiology of cholelithiasis?

The following factors contribute to the formation of stones.

• Metabolic factors –
• Reflux factors -
• Stasis factors -
• Infective factors - 
• Obesity -

1. Metabolic factors:-

Excessive cholesterol in the bile is one of the reasons for gallstone diseases. Few drugs cause increased concentration of cholesterol in the bile like oral contraceptive pills, clofibrate, etc. The solubility of cholesterol depends on the concentration of conjugated bile salts ( bile acid ) and phospholipids. The normal ratio of bile acid to cholesterol is 25:1. But when this ratio alters and falls to 13:1 the cholesterol precipitates and thus stone forms.

2. Reflux factors:-

Reflux of pancreatic enzymes into the gallbladder is also considered the cause of cholesterol precipitation.

3. Stasis factors:-

Long-time stasis of bile in the gall bladder lumen is one of the causes of the formation of pigment stones. In pregnancy, due to excess estrogen hormone bile stasis occurs. Infestation of Ascaris, Clonorchiasis, and E coli increases the stasis of bile. Temporary cessation of bile flow into the intestine and stagnation of bile in the gall bladder is also the cause of stone formation. Stasis may predispose bacterial invasion and stone formation.

4. Infective factors:-

This factor is considered the main cause of stone formation. Helicobacter pylori is a bacteria seen in gall bladder stones. It proves that it is a causative factor for stone formation in the gallbladder. Mixed stones are said to be infective in origin. The causative organisms are – Helicobacter pylori, E. coli, Bacterium typhosum, Streptococcus, etc. 

5. Obesity:-

Obese peoples are more prone to develop gall bladder stones. 

What are the types of Cholelithiasis/Gallbladder stones?

Types of stones on the basis of their chemical nature:

1. Cholesterol stones - 

Stones are formed of cholesterol. These stones are yellow-green in color.

2. Pigment stones – 

Pigment stones are rare and formed of bile pigment bilirubin as calcium bilirubinate salt. These are brown in color.

3. Mixed stones – 

90 % of gallbladder stones are mixed stones. These are the combination of cholesterol, bile pigments calcium, phosphates, protein, and cysteine. 

What are the Causes of Cholelithiasis/Gallbladder stones?

Causes of cholesterol stones:-

When the ratio of bile acid and cholesterol in the bile juice decreases, the precipitation of cholesterol occurs which in turn leads to the formation of cholesterol stones.

The reason being:

Excessive cholesterol.

Excessive bilirubin.

Fewer bile salts.

Parenteral nutrition.

Prolong fasting

Infections 

Causes of pigment stones:-

When excessive bile pigments are excreted in the bile juice the precipitation of bile occurs and pigment stones are formed.

The reason being:

Hemolytic diseases – sickle cell disease, hemolytic anemia, septic hemolysis, malaria.

Cirrhosis

Infections 

What are the Clinical Features of cholelithiasis?

Symptoms:-

Most of the time it remains asymptomatic for a long time.
Patients may be complaining of :

• Pain in right hypochondrium
• Fever with rigor
• Flatulent dyspepsia
• Nausea and vomiting
• jaundice
• Irregular bowel habits with change stool color to clay color.
• Palpitation ( cholecystic heart )

What are the complications of cholelithiasis?

• Acute cholecystitis
• Chronic cholecystitis
• Obstructive Jaundice
• Acute pancreatitis
• Chronic pancreatitis
• Gangrene of gall bladder
• Perforation of gall bladder
• Fistula formation between the duodenum and gallbladder
• Mucocoele
• Hepatitis
• Cholangitis
• Cancer of gall bladder in long term

How to diagnose Cholelithiasis? 

Investigations:-

1. Blood:

Cytological tests-  Total leukocyte count-         increased

                                    Differential leukocyte count- increased neutrophil count

Biochemistry –

Liver function test ( LFT ) - 

                              Serum bilirubin - Direct

                                                        - Indirect

                               Alkaline phosphatase 

                               SGPT - Serum Glutamic Pyruvic Transaminase ( ALT )

                               SGOT - Serum Gluamic Oxaloacetic Transaminase ( AST )

                               GGT - Gamma-glutamyltransferase

Kidney function test ( KFT ) -

                        Blood urea

                        Serum creatinine

2. ECG Electrocardiography- 

ECG is needed to rule out heart pathology which is the common differential diagnosis of cholelithiasis.

3. Radiological examinations-

USG Gallbladder Stone

                                      

1. Straight X-ray abdomen.

2. Ultrasonography of the abdomen, is the most common diagnostic modality for the diagnosis of gall bladder stones.

3. ERCP

4. CT scan abdomen

What is the management/treatment of cholelithiasis? 

Conservative management:

An antibiotic – broad-spectrum antibiotic is given to prevent cholangitis.
Analgesic –
Antispasmodic drugs –
Anticholinergic – given to relax the sphincter of Oddi.
Glucose iv or orally given 

Surgical management:

Cholecystectomy, surgical removal of the gallbladder with stones.

What are the preventions of cholelithiasis?

Physical activity – avoid a sedentary lifestyle. Make routine exercises regularly.
Take a High fiber diet
Take Low cholesterol diet
Avoid prolonged fasting.

ALSO, READ Biliary sludge. Microlithiasis

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References:

- Bailey & Love's Short Practice of Surgery 23rd Edition, Edited by R.C.G. RUSSEL, 

   NORMAN S. WILLIAMS & CHRISTOPHER J. K. BULSTRODE

- A Concise Text Book of Surgery 3rd Edition by S. Das