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developing . Treatment is removal of the CBD stone by ERCP .
Symptoms are probably only pres-
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Table 2 . Factors associated with increased likelihood of gallstones |
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ent in 50 % of patients with stones in the CBD . 17 |
Factor |
Causes |
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Pancreatitis
Biliary pancreatitis may be mild , very severe , and occasionally lethal . Pancreatitis is usually identified in hospital . Patients present with relatively severe episodes of upper abdominal pain , nausea and vomiting , neces-
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GI dysmotility |
Spinal cord injury Weight cycling Prolonged fasting Rapid weight loss Bariatric surgery Total parenteral nutrition Gastrectomy |
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sitating admission , usually through ED . Patients will occasionally present in general practice following a particularly unpleasant 24-48 hours |
Diet |
High calorie High carbohydrate High glycaemic load Low-fibre |
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self-managed at home . Early recurrence of pancreatitis occurs frequently if the gallstones are not expeditiously treated .
If the patient ’ s symptoms resolve to an adequate extent in hospital , early LC and operative cholangiogram are performed because there is a high rate of potential CBD stones and recurrent pancreatitis .
It is frequently noted clinically that patients with multiple small gallbladder calculi on ultrasound are more likely to have pancreatitis than patients with a single large stone . This is not , however , always the case .
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Metabolic syndrome
Drugs
Increased enterohepatic bilirubin cycling
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Insulin resistance Diabetes mellitus Lack of exercise Obesity Non-alcoholic fatty liver disease
Fibrates Octreotide Calcineurin inhibitors Hormone replacement therapy
Ileal resections Crohn ’ s disease Cirrhosis
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Complications of severe pancreatitis |
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include pancreatic necrosis , severe |
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septicaemia , shock , renal failure and |
may increase the risk of gallstones ( see |
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multiorgan failure . Patients may spend |
table 2 ). Gallstones appear to have a |
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months in ICU , with associated signifi- |
hereditary frequency , especially in |
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cant morbidity and mortality . |
the Hispanic population and those of |
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Atypical gallbladder disease in the elderly
Elderly patients frequently present
in an atypical fashion , with only mild
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indigenous American ancestry , as well
25 , 26 as in twins .
PATHOPHYSIOLOGY
THE formation of gallstones may be
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abdominal pain , confusion , fever and malaise . Clinical diagnosis can be particularly difficult , and full investiga- |
associated with the chemical imbalance of cholesterol solubility , promoting cholesterol crystallisation and |
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tion with ultrasound , biochemical and haematological screening , and inflammatory markers may ultimately reveal the diagnosis .
Gallbladder cancer
Gallbladder cancer is rare but may be
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the formation of gallstones ( see figure 8 ). 27 Insulin resistance promotes biliary cholesterol secretion and oestrogen increases gallstone formation . Many patients form supersaturated bile with an increased rate of gallstone formation . 28 |
Figure 5 . Gallbladder polyps . |
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associated with the presence of gallstones . 18 There is some evidence that larger stones carry a higher risk of gall- |
Intestinal factors , including reduced gallbladder motility , small bowel diseases such as Crohn ’ s dis- |
Gallbladder |
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bladder cancer , in some studies up to ninefold . 19 Prophylactic cholecystectomy has been recommended with a |
ease , and major intestinal resection impairing intestinal-hepatic bile circulation , may promote gallstone for- |
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stone size larger than 3cm , but is not |
mation . Gallstones may result from |
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a uniformly accepted indication for |
abnormal bilirubin metabolism , such |
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surgery . |
as haematological diseases with high |
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Asymptomatic gallstones
There is a lack of randomised controlled
trials and systematic reviews
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bilirubin turnover ( see table 2 ).
Prevention
There is currently no pharmacologi-
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regarding the natural history of gall- |
cal prevention advisable in the general |
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bladder stones . Data is poor but sug- |
population . Maintenance of healthy |
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gests 1-4 % of patients per annum with |
body weight and moderate physical |
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asymptomatic gallstones will develop |
activity can be recommended as pre- |
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symptoms ; this is probably more com- |
ventive strategies . |
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mon in areas where gallstones are endemic . 20 , 21 Patients with insulin dependent diabetes are often offered preventive surgery because of the risk of gangrenous cholecystitis , which is highly morbid . |
MANAGEMENT TECHNIQUES
Laparoscopic cholecystectomy
LC is the treatment of choice for the
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EPIDEMIOLOGY
About 20 % of the Caucasian European adult population have gallstones . 22 It is more common in females , and symp-
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management of symptomatic gallstones and has the lowest mortality and morbidity ( see figure 9 ). The procedure can be safely performed in very elderly patients and those with mul- |
Figure 6 . Gallbladder ‘ polyp ’ on ultrasound . |
Polyp |
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tomatic gallstones were found in up to 57 % of women between the ages of 70 and 79 . Some ethnic populations |
tiple comorbidities . The advantages of LC over open surgery are shorter hospital stays ( especially if the proce- |
Planned open surgery may be indicated in a small cohort of patients for |
ERCP
ERCP is an endoscopic technique uti-
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cholangiogram is performed , or before surgery because of the presence of |
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have increased rates , and prevalence |
dure is performed in the absence of |
disease severity or patient factors . |
lised to access the bile duct through |
pancreatitis , jaundice or abnormal |
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has increased with the availability of |
sepsis ), fewer complications , earlier |
Key to LC is adequate control of the |
the duodenum and is used to clear |
liver function tests , or on preopera- |
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high-calorie , high-carbohydrate diets |
recovery and substantially less pain . It |
cystic duct junction with the bile duct |
the CBD of stones ( see figure 10 ). |
tive MRCP . Some 5-9 % of patients may |
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and decreased rates of physical activity . 23 , 24 A large list of external factors |
is unusual for laparoscopic surgery to need to be converted to laparotomy . |
and prevention of bile duct leakage or injury , which is very uncommon . 29 |
Stones in the CBD may be diagnosed at the time of LC , when an operative |
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