Cholecystolithiasis: Classification, Types, Causes, Symptoms, Diagnosis, Treatment and Prognosis

It is the presence of stones in the gallbladder, they develop within it and are hard, pebble-like deposits that develop within the gallbladder.

They can be as small as a grain of sand or as large as a golf ball.

Complications include: acute and chronic cholecystitis , cholangitis , choledocholithiasis, and pancreatitis. Surgery is required if the patient is symptomatic.

Classification and types of cholecystolithiasis

There are 2 main types of cholecystolithiasis:

  • Stones that are made of cholesterol – These are the most common types of cholecystolithiasis. By the way, these cholesterol gallstones are not related to cholesterol levels in the blood.
  • Stones that are made of bilirubin: They are formed during hemolysis, that is, when red blood cells are destroyed and this leads to excessive production of bilirubin in the bile that results in the formation of these types of gallstones.

Causes

The so-called biliary colic is generally triggered by the ingestion of food. After a few minutes, the pain peaks and can be extremely severe.

In general, it is clearly different from the pain associated with duodenal ulcers , which increases slowly and is rarely that severe.

The term ” colic ” is not always accurate, as it is usually severe, continuous pain that lasts for several hours. The pain is not always circumscribed, it is more intense below the right ribs, but it can also be located along the midline.

Radiation to the right back and right shoulder is typical. Nausea is an almost mandatory accompanying symptom. Fat intolerance is very common, although fat intolerance alone, without painful colic, is very common and nonspecific.

Examination during the pain episode usually reveals intensive, sometimes low-grade, tenderness in the gallbladder region and low-grade defense in the right epigastric region.

Epidemiology and demographics

  • Gallstone disease can be found in 20 million Americans. Of these, 2% to 3% (500,000 to 600,000) are treated with cholecystectomies each year.
  • Annual medical expenses for gallbladder surgeries in the US exceed $ 5 billion.
  • The incidence of gallbladder disease increases with age. The highest incidence is in the fifth and sixth decades.

Predisposing factors for gallstones are being female, pregnancy, age over 40 years, family history of gallstones, obesity, ileal disease, oral contraceptives, diabetes mellitus, rapid weight loss, estrogen replacement therapy.

  • Gallstone patients have a 20% chance of developing biliary colic or its complications at the end of a 20-year period.

Other risk factors include:

  • Solid organ transplant.
  • Bone marrow transplant.
  • Diabetes.
  • Inability of the gallbladder to properly empty bile, especially during pregnancy.
  • Liver cirrhosis.
  • Biliary tract infections cause pigmented stone formation.
  • Medical conditions such as chronic hemolytic anemia and sickle cell anemia that cause excessive bilirubin production.
  • Rapid weight loss after a crash diet or after bariatric surgery.

Symptoms of cholecystolithiasis

  • Physical examination is completely normal unless the patient has cholecystolithiasis; 80% of gallstones are asymptomatic.
  • Typical symptoms of cystic duct obstruction include breakthrough, severe, and cramping pain affecting the RUQ.
  • The pain occurs mainly at night and can radiate to the back or right shoulder. It can last from a few minutes to several hours

Etiology

  • 75% of gallstones contain cholesterol and are generally associated with obesity, female sex, diabetes mellitus; Mixed stones are the most common (80%), pure cholesterol stones account for only 10% of stones.
  • 25% of cholecystolithiasis are pigmentary stones (bilirubin, calcium, and variable organic material) associated with hemolysis and cirrhosis. These tend to be black pigment stones that are refractory to medical therapy.
  • 50% of mixed-type stones are radiopaque.

Diagnosis of cholelithiasis

It is assumed that 10% of patients with gallbladder stones also have common bile duct stones. Symptoms vary, typical is intermittent obstructive jaundice, mainly in relation to an attack of pain, pancreatitis or cholangitis.

However, many patients have no or only minor symptoms. Unlike cholecystolithiasis, biliary colic with choledocholithiasis is often associated with vomiting.

About three-quarters of all patients with choledocholithiasis have pain, which is virtually indistinguishable from cholecystolithiasis with respect to location, severity, and radiation.

Pruebas to diagnose cholecystolithiasis

  • Ultrasound of the abdomen.
  • CT scan of the abdomen.
  • Endoscopic retrograde cholangiopancreatography (ERCP).
  • Endoscopic ultrasound.
  • Gallbladder radionuclide scanner.
  • Colangiograma transhepático percutáneo (ACTP).
  • Magnetic resonance cholangiopancreatography (MRCP).
  • Blood tests to check the level of bilirubin.
  • Liver function tests.
  • Pancreatic enzymes.

Differential diagnosis

In general, biliary colic is so typical that it is easily diagnosed.

The following should be excluded in the differential diagnosis: right-sided renal colic, mesenteric vein or artery thrombosis, acute inflammation of a dorsally and cranially placed appendix, duodenal ulcer, hepatitis, and pancreatitis, which is often caused by biliary obstruction.

Epigastric and umbilical hernias are also rare causes of pain. Myocardial infarction and right heart failure with acute liver congestion are two diseases of organs outside the abdomen that can mimic biliary colic.

An acute perihepatitis, seen mainly in young women, can easily be misinterpreted as cholecystolithiasis.

Lab tests

It is usually normal unless the patient has biliary obstruction (elevated alkaline phosphatase, bilirubin).

Imaging study

  • Gallbladder ultrasound will detect small stones and bile sludge (sensitivity 95%; specificity 90%); the presence of a dilated gallbladder with a thickened wall suggests acute cholecystitis.
  • Nuclear imaging (HIDA scan) can confirm acute cholecystitis (> 90% accuracy) if the gallbladder is not visualized within 4 hours of injection and the radioisotope is excreted in the common bile duct.

Treatment

Non-drug therapy

Lifestyle changes (avoidance of diets high in polyunsaturated fats, weight loss in obese patients; however, avoid rapid weight loss).

Other more general treatments:

  • Management of gallstones is affected by the clinical presentation.
  • Asymptomatic patients do not require therapeutic intervention.
  • Surgical intervention is generally the ideal approach for symptomatic patients. Laparoscopic cholecystectomy is generally preferred over open cholecystectomy because of the shorter recovery period.
  • Laparoscopic cholecystectomy after endoscopic sphincterectomy is recommended in patients with common gallstones and residual gallbladder stones.
  • Patients who are not appropriate candidates for surgery due to coexisting conditions or patients who refuse surgery can be treated with oral bile salts: ursodiol (Actigall) 8 to 10 mg / kg / day in two to three divided doses over 16 to 20 months , or chenodiol (Chenix) 250 mg twice daily, gradually increasing to a dose of 60 mg / kg / day.
  • Direct dissolution of the solvent with methyl tert-butyl ether (MTBE) can be used in patients with multiple stones with diameter = 3 cm; This method should be used only by physicians with experience in dissolving contacts.
  • Extracorporeal shock wave lithotripsy (ESWL) is another form of medical therapy. It can be used in patients with a stone diameter of = 3 cm and with three or fewer stones.

Prognosis of cholecystolithiasis

  • The recurrence rate after bile acid treatment is approximately 50% in 5 years. Periodic ultrasound is necessary to evaluate the effectiveness of the treatment.
  • Gallstones recur after dissolution treatment with MTBE in> 40% of patients within 5 years.
  • After extracorporeal shock wave lithotripsy, stones recur in approximately 20% of patients after 4 years.
  • Patients with at least one gallstone less than 5 mm in diameter have a four times greater risk of developing acute biliary pancreatitis. A watchful waiting policy in such cases is generally not justified.
  • A possible serious complication of gallstones is acute cholangitis. ERCP and endoscopic sphincterrectomy (EC) followed by laparoscopic interval cholecystectomy are effective in acute cholangitis.