Cholelithiasis

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  • Topic: Gallstone, Cholecystectomy, Cholecystitis
  • Pages : 6 (1164 words )
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  • Published : February 26, 2013
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Background
Presence of gallstones in the gallbladder.
Spectrum ranges from asymptomatic, colic, cholangitis, choledocholithiasis, cholecystitis Colic is a temporary blockage, cholecystitis is inflammation from obstruction of CBD or cystic duct, cholangitis is infection of the biliary tree. Anatomy

Pathophysiology
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.
Pathophysiology
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. Harvest Time

Frequency
US: affected by race, ethnicity, sex, medical conditions, fertility. 20 million have GS. Every year 1-2% of people develop them. Hispanics are at increased risk. Internationally: 20% of women, 14% of men. Patients over 60 prevalence was 12.9% for men, 22.4% for women. Morbidity/Mortality

Every year 1-3% of patients develop symptoms.
Asymptomatic GS are not associated with fatalities.
Morbidity and mortality is associated only with symptomatic stones. Race
Highest in fair skinned people of northern European descent and in Hispanic populations. High in Pima Indians (75% of elderly). In addition Asians with stones are more likely to have pigmented stones than other populations. African descent with Sickle Cell Anemia.

Sex
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
Oral contraceptives, estrogen replacement tx.
Age
It is uncommon for children to have gallstones. If they do, its more likely that they have congenital anomalies, biliary anomalies, or hemolytic pigment stones. Incidence of GS increases with age 1-3% per year.

History
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. History
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. History

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. Physical

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

Causes
Fair, fat, female, fertile of course.
High fat diet
Obesity
Rapid weight loss, TPN, Ileal disease, NPO.
Increases with age, alcoholism.
Diabetics have more complications.
Hemolytics
Differentials
AAA
Appendicitis
Cholangitis, cholelithiasis
Diverticulitis
Gastroenteritis, hepatitis
IBD, MI, SBO
Pancreatitis, renal colic, pneumonia
Workup
Labs with asymptomatic cholelithiasis and biliary colic should all be normal. WBC, elevated LFTS may be helpful in diagnosis of acute cholecystitis, but normal values do not rule it out. Study by Singer et al examined utility of labs with chole diagnosed with HIDA, and showed no difference in...
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