Gallstones (Cholelithiasis)

Aetiology & Pathophysiology

Aetiology:**

• Cholesterol stones: Associated with obesity, rapid weight loss, high-fat diets, estrogen therapy, and genetic predisposition.
• Pigment stones: Linked to hemolytic disorders (e.g., sickle cell disease), cirrhosis, or biliary infections.

Pathophysiology:**

• Cholesterol supersaturation in bile, coupled with impaired gallbladder motility, promotes crystal nucleation and stone formation.
• Pigment stones result from excess unconjugated bilirubin precipitating with calcium salts.

Symptoms & Signs

Asymptomatic:**

• Majority of cases (silent stones).

Symptomatic presentations:**

• Biliary colic: Episodic right upper quadrant (RUQ) or epigastric pain, often postprandial, lasting hours.
• Acute cholecystitis: Persistent RUQ pain, fever, Murphy’s sign.
• Choledocholithiasis: Jaundice, pale stools, dark urine.

Red-flag symptoms:**

• Signs of complications: Fever, rigors, severe persistent pain, hypotension (suggesting sepsis or pancreatitis).

Diagnosis

Imaging:**

• Abdominal ultrasound (first-line): High sensitivity for detecting stones, gallbladder wall thickening, or duct dilation.
• MRCP (magnetic resonance cholangiopancreatography): For suspected common bile duct (CBD) stones.
• EUS (endoscopic ultrasound) or ERCP: For diagnostic/therapeutic intervention in CBD stones.

Laboratory tests:**

• Elevated bilirubin, ALP, ALT/AST (suggesting biliary obstruction).
• Leukocytosis (in cholecystitis or infection).

Management

Asymptomatic stones:**

• Usually observational; cholecystectomy considered in high-risk groups (e.g., porcelain gallbladder, sickle cell disease).

Symptomatic stones:**

• Laparoscopic cholecystectomy (gold standard for recurrent biliary colic or cholecystitis).
• Medical dissolution therapy (ursodeoxycholic acid) for select small cholesterol stones (limited efficacy).
• ERCP with sphincterotomy: For CBD stones.

Supportive care:**

• Analgesics (NSAIDs, opioids) for pain control.
• Antibiotics for acute cholecystitis or cholangitis.

Potential Complications

• Acute cholecystitis:** Gallbladder inflammation/infection.
• Choledocholithiasis:** CBD obstruction leading to jaundice, cholangitis.
• Gallstone pancreatitis:** Stone migration obstructing the pancreatic duct.
• Gallbladder perforation or empyema.**
• Chronic cholecystitis or biliary-enteric fistula.**

Prevention & Follow-up

Prevention:**

• Maintain a healthy weight; avoid rapid weight loss.
• Balanced diet (reduce saturated fats, increase fibre).

Follow-up:**

• Post-cholecystectomy: Most patients require no long-term follow-up.
• Monitor for postcholecystectomy syndrome (e.g., persistent symptoms) or retained stones.
• High-risk individuals (e.g., cirrhotic patients) may need periodic imaging.