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| Line 48: |
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| [[Gallstone disease case study one|Case #1]] | | [[Gallstone disease case study one|Case #1]] |
|
| |
| == Pathophysiology ==
| |
|
| |
| '''Asymptomatic stones:'''
| |
| 16-26% of patients develop gallstone-related symptoms in 10 years. Prophylactic cholecystectomy ''not'' indicated UNLESS increased risk of gallbladder (gb) cancer:
| |
| :*Pima Indian
| |
| :*calcified gb
| |
| :*gb polyp >10 mm
| |
| :*gallstones >2.5 cm
| |
| :*Salmonella carrier
| |
|
| |
| Diagrams shown below are courtesy of [http://www.wikisurgery.com Wikisurgery.com]
| |
| <div align="center">
| |
| <gallery heights="145" widths="125">
| |
| Image:STEP2330 acute cholecystitis.jpg
| |
| Image:STEP2334 perforation of gallbladder.jpg
| |
| Image:STEP2335 local inflammation around gall bladder.jpg
| |
| Image:STEP2336 perforation of gallbladder.jpg
| |
| Image:STEP2341.empyema and mucocele of gallbladder.jpg
| |
| Image:STEP2346 gallbladder fistula.jpg
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| Image:STEP2350chronic cholecystitis and carcinoma.jpg
| |
| </gallery>
| |
| </div>
| |
|
| |
| ===Symptomatic stones===
| |
| 38-50% of patients have pain recurrence/year after 1 episode biliary colic. 1-2% of patients have complication rate/year.
| |
|
| |
| ==Causes==
| |
| [[Image:Gallstones.jpg|thumb|200px|left|[[Gall bladder]] opened to show numerous '''gallstones'''. Their brownish to greenish color suggest they are cholesterol [[Calculus (medicine)|calculi]].]]
| |
|
| |
| Progress has been made in understanding the process of gallstone formation. Researchers believe that gallstones may be caused by a combination of factors, including inherited body chemistry, [[human weight|body weight,]] gallbladder motility (movement), and perhaps diet. Additionally, people with [[erythropoietic protoporphyria]] (EPP) are at increased risk to develop gallstones.<ref>{{cite web |url=http://www.merck.com/mmhe/sec12/ch160/ch160d.html |title=Erythropoietic Protoporphyria |accessdate=2007-08-25 |work=Merck Manual}}</ref>
| |
|
| |
| Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high concentration of cholesterol, two other factors seem to be important in causing gallstones. The first is how often and how well the gallbladder contracts; incomplete and infrequent emptying of the gallbladder may cause the bile to become overconcentrated and contribute to gallstone formation. The second factor is the presence of proteins in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones.
| |
|
| |
| In addition, increased levels of the hormone [[estrogen]] as a result of [[pregnancy]], [[hormone therapy]], or the use of combined (estrogen-containing) forms of [[hormonal contraception]], may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation.
| |
|
| |
| No clear relationship has been proven between diet and gallstone formation. However, low-fiber, high-cholesterol diets, and diets high in starchy foods have been suggested as contributing to gallstone formation. Other nutritional factors that may increase risk of gallstones include rapid weight loss, constipation, eating fewer meals per day, eating less fish, and low intakes of the nutrients folate, magnesium, calcium, and vitamin C.<ref>{{cite journal |author=R.M. Ortega |coauthors=M. Fernandez-Azuela, A. Encinas-Sotillos, P. Andres, and A. M. Lopez-Sobaler |year=1997 |month=February |title=Differences in diet and food habits between patients with gallstones and controls |journal=Journal of the American College of Nutrition |volume= 16 |pages=88-95 |accessdate= 2007-08-25}}</ref> On the other hand, wine and whole grain bread may decrease the risk of gallstones.<ref>{{cite journal |year=1995 |month=June |title=. |journal=European Journal Gastroenterology & Hepatology |volume=6 |pages=585-593 |accessdate= 2007-08-25}}</ref>
| |
|
| |
| === Common Causes ===
| |
|
| |
| *[[Aging]]
| |
| *[[Clofibrate]]
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| *[[Combined oral contraceptive pill]]
| |
| *[[Diabetes]]
| |
| *[[Fasting]]
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| *[[Hemolytic anemia]]
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| *[[Inflammatory bowel disease]]
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| *[[Obesity]]
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| *[[Pregnancy]]
| |
|
| |
| === Causes by Organ System ===
| |
|
| |
| {|style="width:80%; height:100px" border="1"
| |
| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
| |
| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Williams syndrome]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Chemical / poisoning'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Dermatologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Drug Side Effect'''
| |
| |bgcolor="Beige"| [[Ceftriaxone]], [[Clofibrate]], [[Combined oral contraceptive pill]], [[Hormonal contraception]], [[Lanreotide]], [[Pasireotide]], [[Proton pump inhibitors]], [[Somatostatin]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Ear Nose Throat'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Endocrine'''
| |
| |bgcolor="Beige"| [[Diabetes]], [[Somatostatinoma]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Environmental'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Gastroenterologic'''
| |
| |bgcolor="Beige"| [[Crohn's disease]], [[Liver cirrhosis]], [[Ulcerative colitis]], [[Cystic fibrosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Genetic'''
| |
| |bgcolor="Beige"| [[Erythropoietic protoporphyria]], [[Hemochromatosis]], [[Hereditary spherocytosis]], [[Williams Syndrome ]], [[Hemoglobin E disease]], [[Hemolytic anemia]], [[Sickle cell disease]], [[Cystic fibrosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Hematologic'''
| |
| |bgcolor="Beige"| [[Hemoglobin E disease]], [[Hemolytic anemia]], [[Sickle cell disease]], [[Hemochromatosis]], [[Hereditary spherocytosis]], [[Erythropoietic protoporphyria]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Iatrogenic'''
| |
| |bgcolor="Beige"| [[Long term intravenous nutrition]], [[Weight loss surgery]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Infectious Disease'''
| |
| |bgcolor="Beige"| [[Clonorchiasis]], [[Infection in the gallbladder]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Musculoskeletal / Ortho'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Neurologic'''
| |
| |bgcolor="Beige"| [[Williams syndrome]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Nutritional / Metabolic'''
| |
| |bgcolor="Beige"| [[Hypercalcaemia]], [[Low-fibre, high-cholesterol diets]], [[Hemochromatosis]], [[Williams syndrome]], [[Erythropoietic protoporphyria]], [[Dieting]], [[Fasting]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Obstetric/Gynecologic'''
| |
| |bgcolor="Beige"| [[Pregnancy]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Oncologic'''
| |
| |bgcolor="Beige"| [[Somatostatinoma]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Opthalmologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Overdose / Toxicity'''
| |
| |bgcolor="Beige"| [[Ceftriaxone]], [[Clofibrate]], [[Combined oral contraceptive pill]], [[Hormonal contraception]], [[Lanreotide]], [[Pasireotide]], [[Proton pump inhibitors]], [[Somatostatin]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Psychiatric'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Pulmonary'''
| |
| |bgcolor="Beige"| [[Cystic fibrosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Renal / Electrolyte'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Rheum / Immune / Allergy'''
| |
| |bgcolor="Beige"| [[Ulcerative colitis]], [[Crohn's disease]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Sexual'''
| |
| |bgcolor="Beige"| [[Cystic fibrosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Trauma'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Urologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Dental'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Miscellaneous'''
| |
| |bgcolor="Beige"| [[Aging]], [[Dieting]], [[Fasting]], [[Obesity]], [[Rapid weight loss]]
| |
| |-
| |
| |}
| |
|
| |
| === Causes in Alphabetical Order ===
| |
|
| |
| {{MultiCol}}
| |
| *[[Aging]]
| |
| *[[Ceftriaxone]]
| |
| *[[Clofibrate]]
| |
| *[[Clonorchiasis]]
| |
| *[[Combined oral contraceptive pill]]
| |
| *[[Crohn's disease]]
| |
| *[[Cystic fibrosis]]
| |
| *[[Diabetes]]
| |
| *[[Dieting]]
| |
| *[[Erythropoietic protoporphyria]]
| |
| *[[Fasting]]
| |
| *[[Hemochromatosis]]
| |
| *[[Hemoglobin E disease]]
| |
| *[[Hemolytic anemia]]
| |
| *[[Hereditary spherocytosis]]
| |
| *[[Hormonal contraception]]
| |
| *[[Hypercalcaemia]]
| |
| {{ColBreak}}
| |
| *[[Infection in the gallbladder]]
| |
| *[[Lanreotide]]
| |
| *[[Liver cirrhosis]]
| |
| *[[Long term intravenous nutrition]]
| |
| *[[Low-fibre, high-cholesterol diets]]
| |
| *[[Obesity]]
| |
| *[[Pasireotide]]
| |
| *[[Pregnancy]]
| |
| *[[Proton pump inhibitors]]
| |
| *[[Rapid weight loss]]
| |
| *[[Sickle cell disease]]
| |
| *[[Somatostatin]]
| |
| *[[Somatostatinoma]]
| |
| *[[Ulcerative colitis]]
| |
| *[[Weight loss surgery]]
| |
| *[[Williams Syndrome ]]
| |
| {{EndMultiCol}}
| |
|
| |
| == Risk Factors ==
| |
| *More common in females.
| |
| *Obesity
| |
| *Common amongst Pima Indians, North Americans and Chileans.
| |
| *Generally Japanese have the lowest incidence of stones.
| |
| *Sudden weight loss
| |
| *Prolonged fasting.
| |
| *Pregnancy
| |
| *Presence of Crohn's disease.
| |
| *Cystic fibrosis
| |
| *Diabetes,
| |
| *Liver cirrhosis
| |
| *Increasing age
| |
| *Extensive bowel resection
| |
| *Use of contraceptives and other medications like largactil, octreotide, and clofibrate
| |
| ==Diagnosis==
| |
| ===History and Symptoms===
| |
| Gallstones usually remain asymptomatic initially.<ref>{{cite web |url=http://www.emedicine.com/med/topic836.htm#section~clinical |title=Cholelithiasis |accessdate=2007-08-25 |work=emedicine from WebMD}}</ref> They start developing symptoms once the stones reach a certain size (>8mm).<ref>{{cite web |url=http://www.nlm.nih.gov/medlineplus/ency/article/000273.htm#Symptoms%20Medline%20Plus |title=Gallstones |accessdate=2007-08-25 |work=Medline Plus}}</ref> A main symptom of gallstones is commonly referred to as a gallstone "attack", also known as '''biliary colic''', in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately thirty minutes to several hours. A victim may also encounter pain in the back, ordinarily between the shoulder blades, or pain under the right shoulder. In some cases, the pain develops in the lower region of the abdomen, nearer to the pelvis, but this is less common.
| |
| ====Biliary colic====
| |
| '''Biliary colic''' is [[pain]] associated with irritation of the viscera secondary to [[cholecystitis]] and gallstones. Unlike renal colic, the phrase 'biliary colic' refers to the actual [[cholelithiasis]].
| |
|
| |
| Though unlike renal colic, the phrase 'biliary colic' refers to the actual cholelithiasis. Although it is frequently described as
| |
| a [[colic]], the pain is steady, starts rapidly and lasts at least 30 minutes and up to several hours. Many patients complain of right upper quadrant pain, rt flank pain, or even mid chest pain with cholelithiasis. There may be
| |
| irradiation to the back and shoulders and other concomitant symptoms such as [[vomiting]] and [[diarrhea]]. Fatty foods
| |
| can provoke biliary pain, but this association is relatively non-specific.
| |
|
| |
| Biliary pain can be associated with objective findings (dilation of the biliary tract, elevation of plasma liver enzyme
| |
| concentration, elevation of bilirubin, gamma-GT and alkaline phosphatase).
| |
| =====Causes=====
| |
| Biliary pain is most frequently caused by obstruction of the [[common bile duct]] or the [[cystic duct]] by a [[gallstone]]. However,
| |
| the presence of [[gallstones]] is a frequent incidental finding and does not always necessitate treatment,
| |
| in the absence of identifiable disease. Furthermore, biliary pain may be associated with functional disorders of the
| |
| biliary tract, so called acalculous biliary pain, and can even be found in patients post-cholecystectomy (removal
| |
| of the gallbladder), possibly as a consequence of dysfunction of the [[biliary tree]] and the sphincter of oddi.
| |
| =====Differential Diagnosis=====
| |
| *Amoebic liver abscess
| |
| *Perforated peptic ulcer
| |
| *Upper small bowel obstruction.
| |
| =====Complications=====
| |
| The more serious complication is total blockage of the bile duct which leads to [[jaundice]], which if it is not corrected naturally or by a surgical procedure can be fatal as it causes [[liver]] damage.
| |
|
| |
| The presence of gallstones can lead to infection of the gall bladder (cholecystitis) or the biliary tree
| |
| (cholangitis) or acute inflammation of the pancreas (pancreatitis). Rarely, an impacted gallstone can obstruct
| |
| the bowel, causing [[gallstone ileus]] (mechanical [[ileus]]).
| |
|
| |
| Biliary pain in the absence of gallstones may severely impact the patient's quality of life, even in the absence
| |
| of disease progression.
| |
| =====Presentation=====
| |
| This condition causes crescendos of severe pain in the [[right upper abdomen]] and sometimes through to the upper [[back]] and/or right shoulder. The pain relates to the obstruction of the passage of bile and can be associated with eating fatty foods. There is usually an inflammatory component to the pain as the characteristic colic is not completely relieved between crescendos.
| |
|
| |
| Often, these attacks occur after a particularly fatty meal and almost always happen at night.
| |
| =====Treatment=====
| |
| These attacks are intensely painful, similar to that of a [[kidney stone]] attack. One way to alleviate the abdominal pain is to drink a full glass of water at the start of an attack to regulate the bile in the [[gallbladder]], but this does not work in all cases. Another way is to take magnesium followed by a bitter liquid such as [[coffee]] or [[swedish bitters]] an hour later. Bitter flavors stimulate bile flow. A study has found lower rates of gallstones in coffee drinkers.<ref>{{cite web |url=http://jama.ama-assn.org/cgi/content/abstract/281/22/2106t |title=A Prospective Study of Coffee Consumption and the Risk of Symptomatic Gallstone Disease in Men |accessdate=2007-08-25 |work=The Journal of the American Medical Association}}</ref>
| |
|
| |
| Pain management is an important part of treating biliary colic. Treatment is often with [[NSAIDs]] such as [[ketorolac]] (Toradol) and [[diclofenac]] (Voltaren). [[Hyoscine butylbromide]] (Buscopan) is occasionally used but is less effective than analgesics.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=882 |title=BestBets: Buscopan (hyoscine butylbromide) in biliary colic. |format= |work= |accessdate=}}</ref>
| |
|
| |
| ====Other symptoms====
| |
| Other symptoms include
| |
| *[[Jaundice]]
| |
| *[[Nausea]] and [[vomiting]]
| |
| *[[Diarrhea]]
| |
| *[[Bleeding]] caused by continuous vomiting
| |
| *[[Dehydration]] caused by the nausea and diarrhea.
| |
| *Abdominal bloating
| |
| *Intolerance of fatty foods
| |
| *Belching
| |
| *Indigestion.
| |
| If the above symptoms coincide with chills, [[low-grade fever|lowgrade fever]], yellowing of the skin or eyes, and/or clay-colored stool, a doctor should be consulted immediately.<ref name="nih_gall">{{cite web |url=http://digestive.niddk.nih.gov/ddiseases/pubs/gallstones/index.htm#symptoms |title=Gallstones |accessdate=2007-08-25 |work=National Digestive Diseases Information Clearinghouse}}</ref>
| |
|
| |
| Some people who have gallstones are asymptomatic and do not feel any pain or discomfort. These gallstones are called "silent stones" and do not affect the [[gallbladder]] or other internal organs. They do not need treatment.<ref name="nih_gall"/>
| |
|
| |
| ===Ultrasound ===
| |
|
| |
| Test of choice
| |
| * 95% sensitivity and specificity for gallstones >2 mm diameter
| |
| * stones better visualized if patient is fasting
| |
|
| |
|
| === Other Imaging Findings === | | === Other Imaging Findings === |
Template:DiseaseDisorder infobox
For patient information click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Prashanth Saddala M.B.B.S
Synonyms and related keywords: Cholecystolithiasis; choleliths; cholelithiasis; biliary colic; gall stones; gallbladder calculus.
Diagnosis
History and Symptoms | Physical Examination | Laboratory Findings | X Ray | CT | MRI | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies
Case Studies
Case #1
Other Imaging Findings
- Endoscopic Retrograde Cholangiopancreatography (ERCP): most sensitive/specific for common bile duct (CBD) stones
- Magnetic Resonance Cholangiopancreatography (MRCP): diagnostic accuracy equivalent to ERCP, but not therapeutic
- Hepatobiliary Iminodiacetic Acid (HIDA) scan: highly sensitive for acute cholecytitis
Patient #1: Gallstone on MRI
Patient #2: A large gallstone in a patient with Autosomal dominant polycystic kidney disease
Treatment
Nonoperative management is suboptimal (ursodiol, lithotripsy). Cholecystectomy is the therapy of choice.
Medical therapy
Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid. Gallstones may recur however, once the drug is stopped. Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphinceterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP). A common misconception is that the use of ultrasound (Extracorporeal Shock Wave Lithotripsy) can be used to break up gallstones. Although this treatment is highly effective against kidney stones, it can only rarely be used to break up the softer and less brittle gallstones.
Surgery
Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients must be indicated to surgery. The lack of a gall bladder does not seem to have any negative consequences in many people. However, there is a significant proportion of the population, between 5-40%, who develop a condition called postcholecystectomy syndrome.[1] Symptoms include gastrointestinal distress and persistent pain in the upper right abdomen.
There are two surgery options: open procedure and laparoscopic: see the cholecystectomy article for more details.
- Open cholecystectomy procedure: This involves a large incision into the abdomen (laparotomy) below the right lower ribs. A week of hospitalization, normal diet a week after release and normal activity a month after release.
- Laparoscopic cholecystectomy: 3-4 small puncture holes for camera and instruments (available since the 1980s). Typically same-day release or one night hospital stay, followed by a week of home rest and pain medication. Can resume normal diet and light activity a week after release. (Decreased energy level and minor residual pain for a month or two.) Studies have shown that this procedure is as effective as the more invasive open cholecystectomy, provided the stones are accurately located by cholangiogram prior to the procedure so that they can all be removed. The procedure also has the benefit of reducing operative complications such as bowel perforation and vascular injury.
Alternative medicine
A regimen called a "gallbladder flush" or "liver flush" is a popular remedy in alternative medicine. In this treatment, often self-administered, the patient drinks four glasses of apple cider and eats five apples per day for five days, then fasts briefly, takes magnesium, and then drinks large quantities of lemon or grapefruit juice mixed with olive oil or other oil before bed; the next morning, they painlessly pass a number of green and brown pebbles purported to be stones flushed from the biliary system. A New Zealand hospital analyzed stones from a typical gallbladder flush and found them to be composed of fatty acids similar to those in olive oil, with no detectable cholesterol or bile salts,[2] demonstrating that they are little more than hardened olive oil. Despite the gallbladder flush, the patient still required surgical removal of multiple true gallstones. The note concluded: "The gallbladder flush may not be entirely worthless, however; there is one case report in which treatment with olive oil and lemon juice resulted in the passage of numerous gallstones, as demonstrated by ultrasound examination."[3]
In the case mentioned, ultrasound confirmed multiple gallstones, but after waiting months for a surgical option, the patient underwent a treatment with olive oil and lemon juice resulting in the passage of four 2.5 cm by 1.25 cm stones and twenty pea-sized stones. Two years later symptoms returned, and ultrasound showed a single large gallstone; the patient chose to have this removed surgically.[3]
References
External links
Template:WikiDoc Sources
