CHOLELITHIASIS (Gallstones) 

1. Definition

Cholelithiasis = presence of stones in the gallbladder.

  • May be asymptomatic
  • May present as biliary colic
  • May lead to complications:
    Acute cholecystitis, choledocholithiasis, cholangitis, pancreatitis


2. Epidemiology

  • Prevalence: 10–20% adults in Western population
  • Increasing in India
  • Female > Male (2–3:1)
  • Incidence rises with age

Classic mnemonic:
“4 F’s” – Female, Fat, Forty, Fertile


3. Types of Gallstones

A. Cholesterol Stones (Most common – 70–80%)

Features:

  • Yellow
  • Radiolucent on X-ray
  • Formed due to cholesterol supersaturation

Pathogenesis 

  1. ↑ Cholesterol secretion into bile
  2. ↓ Bile salts / phospholipids
  3. Gallbladder stasis
  4. Nucleation → crystal aggregation


B. Pigment Stones

1. Black Pigment Stones

  • Hard, brittle
  • Associated with:
    • Haemolysis
    • Cirrhosis

2. Brown Pigment Stones

  • Soft
  • Associated with:
    • Infection
    • Biliary stasis
    • Common in Asia
    • Often in bile ducts


4. Risk Factors 

Risk Factor

Mechanism

Female sex

Oestrogen ↑ cholesterol secretion

Pregnancy

Progesterone → gallbladder stasis

Obesity

↑ Cholesterol synthesis

Rapid weight loss

↑ Cholesterol mobilisation

TPN

Gallbladder stasis

Ileal disease / resection

↓ Bile salt reabsorption

Diabetes

Dysmotility

Haemolysis

↑ Unconjugated bilirubin


5. Clinical Presentation

A. Asymptomatic (Most common)

  • Incidental finding on ultrasound
  • No treatment required

B. Biliary Colic

Pain characteristics:

  • Severe RUQ or epigastric pain
  • Radiates to right shoulder/scapula
  • Lasts 30 minutes – 6 hours
  • Often after fatty meal
  • No fever

Mechanism:
Transient cystic duct obstruction


C. Complications

Condition

Mechanism

Acute cholecystitis

Persistent cystic duct obstruction

Choledocholithiasis

Stone in CBD

Cholangitis

CBD obstruction + infection

Pancreatitis

Ampullary obstruction

Gallstone ileus

Fistula formation

Mirizzi syndrome

Stone compressing common hepatic duct


6. Investigation

 First Line: Ultrasound Abdomen

Typical findings:

  • Echogenic focus
  • Posterior acoustic shadow
  • Mobile with position change

Sensitivity > 95%


LFT Pattern

  • Normal in simple biliary colic
  • Cholestatic pattern if CBD obstruction:
    • ↑ ALP
    • ↑ GGT
    • ↑ Bilirubin


When to do MRCP?

  • Suspected choledocholithiasis
  • Dilated CBD
  • Abnormal LFTs


7. Management

A. Asymptomatic Gallstones

No treatment

Exceptions 

  • Porcelain gallbladder
  • Gallstones >3 cm
  • Sickle cell disease
  • Gallbladder polyps >1 cm
  • Planned bariatric surgery


B. Biliary Colic

Acute Episode:

  • NSAIDs (first-line: diclofenac IM)
  • Opioids if needed
  • Antiemetics

Definitive:

  • Elective laparoscopic cholecystectomy


C. Acute Cholecystitis

  • Admit
  • IV antibiotics
  • Early laparoscopic cholecystectomy (within 72 hours preferred)


D. Medical Dissolution Therapy

  • Ursodeoxycholic acid
  • Only for:
    • Small cholesterol stones
    • Functioning gallbladder
    • Patient unfit for surgery
  • High recurrence rate


E. ERCP Indications

  • CBD stones
  • Cholangitis
  • Obstructive jaundice


8. Complications of Cholelithiasis

# Acute Cholecystitis(Persistent obstruction → inflammation)

# Gallstone Pancreatitis(Transient ampullary obstruction)

# Ascending Cholangitis

Charcot triad:

  • Fever
  • Jaundice
  • RUQ pain

Reynolds pentad:

  • Hypotension
  • Confusion


9. Clinical Differentials

Scenario

Likely Diagnosis

RUQ pain + fever + raised WCC

Cholecystitis

RUQ pain + jaundice + cholestatic LFT

CBD stone

Severe epigastric pain + ↑ amylase

Gallstone pancreatitis

Elderly + small bowel obstruction

Gallstone ileus

10. Gallstone Ileus

Rigler triad:

  • Pneumobilia
  • Small bowel obstruction
  • Ectopic gallstone


11. Mirizzi Syndrome

Stone in cystic duct compresses common hepatic duct → obstructive jaundice.


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