Cholelithiasis

Question 1

What is cholelithiasis?

Answer 1

Disease of hepatobilliary system caused by infringement of an exchange of cholesterol and/or bilirubin characterised by formation of stones in bile bladder and or in bile ducts with possible development of dangerous complications

Question 2

Etiology of cholelithiasis

Answer 2

Chronic infection of gallbladder-cholecystitis
Hypomotor dyskinesia of bile ducts
Disorders of lipid metabolism of hypercholesteremia type

Predisposing factors - the 5 F’s list

1.Female
2.Fertile
3.Fat
4.Fair
5.Forty
Pregnancy
Disorders of diet regime
Abuse of cholesterol rich food
Heredity

Question 3

Pathogenesis of cholelithiasis

Answer 3

Due to participation of bile acids in enterohepatic circulation or disbalance between concentration of phospotides and cholesterol in bile , it results in precipitation of crystals of cholesterol from the oversaturated bile which then shape a nucleus and form a stone
Pigmentary stones consist of unsolvable precipitates of Calcium and bilirubin(bilirubinate calcium)
Brown pigmented stones may consist of bilirubinate calcium, mild and are rarely formed

There are stages in Pathogenesis
1. Preclinical stage
- disorders in metabolism of cholesterol, bile acids,phospholipids
-
2.Clinical stage
a.physico-chemical stage- impairment of colloid stability of bile, inflammation
b.stage of formation of microliths-agglomeration of particles and formation of microliths, inflammation,dyskinesia
c.Stage of microlithiasis and complications-agglomeration of microliths into macroliths,inflammation,dyskinesia
d.stage of complications-stage of obstruction and dilation of bile ducts

By composition- stones may be cholesterol, bilirubinate based or mixed
In long term carriage carbon and phosphate salts deposit in the stones and they undergo calcification

Question 4

Clinical picture of cholelithiasis

Answer 4

1. typical painful form
2. torpid painful form
3. dyspeptic form
4. asymptomstic form or carriages

Typical form;
With biliary colic or cholecystalgia attacks
Patient feels a strong colicky pain in the right hypochondrion
Irradiation to the right chest,upper arm and shoulder.
Quality of pain-cutting and tearing
Pain appears all of a sudden, mostly at night, 3-4hrs after supper and may last several days
Provoking factor is use of fat,fried smoked food,eggs,cakes,
Pain is strong and may lead to collapse or shock
On examination patient is restless and tries to find a position to relieve pain
Pain is often accompanied by different dyspeptic disorders, temperature is increased,abdomen bloated.
Skin hyperesthesia is expressed in the right hypochondrion with sharp pain fullness to palpation in the right hypochondrion
All symptoms of cholecystitis are highly positive
If stone blocks common bile duct the patient exhibits obstructive jaundice with decolourized stools anddark urine
Blood tests show increased conjugated bilirubin (direct van den Berghs test with Ehrlichs Diazo reagent)
Palpation reveals an enlarged gallbladder (couvvoisiers symptom)

Torpid form;
Absence of evident pain syndrome
Pain in right hypochondrion is weak but persistent and not moved by any means

Dyspeptic form;
Pain is of secondary importance
Patient is disturbed by different dyspeptic phenomena like nausea, mouth bitterness, a feeling of heaviness in the epigastrium, a tendency to constipation and diarrhoea
Systemic symptoms like weakness,malaise,irritability

Latent form;
Subjective symptoms are absent
A patient may carry silent stones in the gallbladder for many years and not suspect their presence
Stones are revealed in post-mortem exam in patient who died from other diseases

Complications of cholelithiasis

• adhesion of organs in abdominal cavity
• Dee a of gallbladder (when it’s function is shut off by obstruction of the cystic duct with a stone)
• empyema(suppuration of gallbladder
• perforation with development of biliary peritonitis
• cholangitis manifested by temperature spikes accompanied by cold shivering
• reactive pancreatitis
• chronic reactive pancreatitis
• solar plexitis

Question 5

Diagnosis of cholelithiasis

Answer 5

• abdominal US
• CBC
• Biochemical
• urine
• ECG

Question 6

Treatment of Cholelithiasis

Answer 6

1.Chemical dissolution of gallstones by preparations of bile acids e.g Ursodiol
Treatment is administered if;
-the diameter of the stone does not exceed 1,5cm
- if gallstones fill not more than 1/3 of the volume of the gallbladder
-function of the gallbladder is fully preserved
-gall stones are not calcified that is they are invisible in the survey radiography of the gallbladder
Duration of treatment 6-12 month
If during this time stones don’t dissolve treatment is interrupted

2.Dissolution of the stones using a thin multichannel tube introduced into the gallbladder during FGS
The stone is washed away by isopropyl or isobutyl ethers

3. Laparoscopic cholecystectomy
4. Cholecystectomy with traditional surgical access