Gallstones

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Gallstones. The predominantly yellow colour suggests cholesterol is the main component, but the darker edges suggest the presence of pigment.

Common (as many as 10-20% above the age of 60). Mostly asymptomatic. Risk of developing symptoms is between 1-4% per year.

The term gallstone disease usually refers to gallstones that have become symptomatic, whereas the simple presence of gallstones is termed cholelithiasis.

Contents

Pathology

Cholesterol stones are the commonest and so define the usual epidemiology. However pigment stones are more likely to be associated with pathology such as chronic infections or sickle cell anaemia where interventions to address the risk factors do seem to work.

Epidemiology

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Prevalence

Exact prevalence varies with age and several risk factors, including genetics and environment (see right). Exact numbers will also depend on detection method (autopsy vs. ultrasound) as well as ethnicity and/or geography. In various case series the three types of stones are found[1]:

  • Cholesterol stones - 37-86%
  • Pigment stones - 2-27%
  • Calcium stones (ie radio-opaque) - 1-17%
  • Mixed stones - 4-16%
  • Other - < 5%

Cholesterol stones are particularly prevalent in:

  • American Indians (as much as ~70%).[2]
  • Germany - 6.0%, but 13.7% in 51-65 year olds[3]
  • Iran - 6.3%[4]
  • Italy - 26.7%[5]
  • Norway - 21.9%[6]
  • Siberia[7]
  • Taiwan[8]

Presentations

Investigations

Ultrasound image of gallstones within the gallbladder

If acute pain

Treatment

Nothing if asymptomatic. Apart from pigmented stones addressing the risk factors has no evidence of efficacy after stones are discovered.

Analgesia

Rectal or parenteral usually as vomiting common:

  • NSAID
  • Morphine (Pethidine has potential toxicity and little in vivo evidence for its differential smooth muscle relaxant properties)

Surgery

There is strong evidence for a conservative approach in asymptomatic gallstones. This includes much higher cholecystectomy rates in some countries such as the United States than others without the overall mortality and morbidity evidence of benefit on a population basis. As asymptomatic gallstones develop gallstone-related problems at a rate of 1%-4% a year, and small stones being more dangerous than large as they can cause pancreatitis, there is a good case for surgical intervention once symptoms develop. Optimisation of such surgical care pathways has been challenging but it is now known for example that optimal outcome in mild gallstone associated pancreatitis is associated with surgical rather than medical admission[10] and appropriate cholecystectomy during the index admission[11].

Symptomatic gallstones are traditionally treated by cholecystectomy, now commonly done as day-case laparoscopic cholecystectomy[12] in most patients with high risk patients(eg previous surgery with adhesions) having percutaneous cholecystostomy. Biliary obstruction is now almost always now treated by ERCP.

Drugs

Bile acids, e.g. ursodeoxycholic acid, have a low efficacy as a primary treatment.[13][14]

It is of no use in symptomatic gallstones.[15]

There are important specific indications (and contra-indications) for active therapies such as ursodeoxycholic acid which is useful to prevent gallstones in the period after bariatric surgery or if a patient has to take somatostatin analogues. This drug will dissolve two-thirds of radiolucent stones less than 5 mm in diameter which are rarely symptomatic at this size but will be if allowed to become bigger in situations of clear therapeutic risk.

References

  1. Gurusamy KS, Davidson BR. Gallstones. BMJ (Clinical research ed.). 2014; 348:g2669.(Epub)
  2. Sampliner RE, Bennett PH, Comess LJ, Rose FA, Burch TA. Gallbladder disease in pima indians. Demonstration of high prevalence and early onset by cholecystography. The New England journal of medicine. 1970 Dec 17; 283(25):1358-64.
  3. Kratzer W, Kächele V, Mason RA, Hill V, Hay B, Haug C, Adler G, Beckh K, Muche R. Gallstone prevalence in Germany: the Ulm Gallbladder Stone Study. Digestive diseases and sciences. 1998 Jun; 43(6):1285-91.
  4. Farzaneh E, Zavvareh HT, Gharadaghi J, Sheikhvatan M. Prevalence and characteristics of gallstone disease in an Iranian population: a study on cadavers. Hepatobiliary & pancreatic diseases international : HBPD INT. 2007 Oct; 6(5):509-12.
  5. Lirussi F, Nassuato G, Passera D, Toso S, Zalunardo B, Monica F, Virgilio C, Frasson F, Okolicsanyi L. Gallstone disease in an elderly population: the Silea study. European journal of gastroenterology & hepatology. 1999 May; 11(5):485-91.
  6. Glambek I, Kvaale G, Arnesjö B, Søreide O. Prevalence of gallstones in a Norwegian population. Scandinavian journal of gastroenterology. 1987 Nov; 22(9):1089-94.
  7. Reshetnikov OV, Ryabikov AN, Shakhmatov SG, Malyutina SK. Gallstone disease prevalence in Western Siberia: cross-sectional ultrasound study versus autopsy. Journal of gastroenterology and hepatology. 2002 Jun; 17(6):702-7.
  8. Chen CH, Huang MH, Yang JC, Nien CK, Etheredge GD, Yang CC, Yeh YH, Wu HS, Chou DA, Yueh SK. Prevalence and risk factors of gallstone disease in an adult population of Taiwan: an epidemiological survey. Journal of gastroenterology and hepatology. 2006 Nov; 21(11):1737-43.(Link to article – subscription may be required.)
  9. a b Glasgow RE, Cho M, Hutter MM, Mulvihill SJ. The spectrum and cost of complicated gallstone disease in California. Archives of surgery (Chicago, Ill. : 1960). 2000 Sep; 135(9):1021-5; discussion 1025-7.
  10. Kulvatunyou N, Watt J, Friese RS, Gries L, Green DJ, Joseph B, O'Keeffe T, Tang AL, Vercruysse G, Rhee P. Management of acute mild gallstone pancreatitis under acute care surgery: should patients be admitted to the surgery or medicine service? American journal of surgery. 2014 Dec; 208(6):981-7; discussion 986-7.(Link to article – subscription may be required.)
  11. de Mestrale C, Nathens AB. Cholecystectomy in mild gallstone pancreatitis: don't defer, Lancet 386:10000:1218–1219; 26 September 2015
  12. Sanders G, Kingsnorth AN. Gallstones. BMJ (Clinical research ed.). 2007 Aug 11; 335(7614):295-9.(Link to article – subscription may be required.)
  13. Schoenfield LJ, Lachin JM. Chenodiol (chenodeoxycholic acid) for dissolution of gallstones: the National Cooperative Gallstone Study. A controlled trial of efficacy and safety. Annals of internal medicine. 1981 Sep; 95(3):257-82.
  14. Fisher MM, Roberts EA, Rosen IE, Shapero TF, Sutherland LR, Davies RS, Bacchus R, Lee SV. The Sunnybrook Gallstone Study: a double-blind controlled trial of chenodeoxycholic acid for gallstone dissolution. Hepatology (Baltimore, Md.). 1985 Jan-Feb; 5(1):102-7.
  15. Venneman NG, Besselink MG, Keulemans YC, Vanberge-Henegouwen GP, Boermeester MA, Broeders IA, Go PM, van Erpecum KJ. Ursodeoxycholic acid exerts no beneficial effect in patients with symptomatic gallstones awaiting cholecystectomy. Hepatology (Baltimore, Md.). 2006 Jun; 43(6):1276-83.(Link to article – subscription may be required.)

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