II. Epidemiology

  1. Cholelithiasis affects 20 million in United States
  2. Cholecystectomies per year in U.S.: 300,000
  3. Management complications result in 6000 US deaths/year
  4. Cholelithiasis Incidence increases with age
    1. However children have an Incidence of Gallstones of 1.9%
  5. Females are more often affected after Puberty
    1. Prior to Puberty, males and females have equal Incidence of Gall Bladder disorders

III. Definitions

  1. Biliary Colic
    1. Transient cystic duct obstruction
  2. Cholelithiasis
    1. Presence or formation of Gallstones
  3. Acute Cholecystitis
    1. Persistent obstruction of the cystic duct
  4. Choledocholithiasis
    1. Calculi in the common bile duct
  5. Acute Gallstone Cholangitis (Ascending Cholangitis)
    1. Acute biliary tract infection caused by bacteria ascending from the Small Intestine

IV. Risks Factors: Cholesterol Gallstones

  1. Classic 5 F's
    1. Female
    2. Forty (age over 40 years)
    3. Fair skinned (Scandinavian)
    4. Family History (first degree relative)
      1. Specific races (e.g. Chilean Indians, Mexican Americans, Pima Indians)
    5. Fat (Obesity with BMI >30)
      1. This applies to children as well
  2. Dietary factors
    1. High calorie diet
    2. Excessive intake of refined carbohydrates
    3. Low fiber intake
    4. Prolonged Fasting
    5. Rapid weight loss (e.g. post-Bariatric Surgery)
    6. Total Parenteral Nutrition (TPN) Cholestasis
      1. Common cause in children with serious comorbidity
  3. Associated Conditions
    1. Alcoholic Cirrhosis
    2. Bariatric Surgery
    3. History of ileal disease, resection or bypass
    4. Diabetes Mellitus, Metabolic Syndrome or Hyperinsulinism
    5. Hyperlipidemia (dyslipidemia)
    6. Obesity
    7. Pregnancy
    8. Sickle Cell Anemia (common cause in children)
  4. Medications
    1. Estrogen Replacement (e.g. Premarin)
    2. Oral Contraceptives
    3. Ceftriaxone

V. Pathophysiology

  1. Gall Stones
    1. Solid calculi form when there is impaired gallbladder motility
    2. Composition
      1. Cholesterol stones (80% of Gallstones in U.S.)
        1. Cholesterol and bile supersaturation which precipitates into Cholesterol monohydrate crystals
      2. Black pigment stones (20% of Gallstones in U.S.)
        1. Polymerized calcium Bilirubinate
  2. Progression to symptoms
    1. Gallbladder distention (hydrops)
    2. Serosal edema
    3. Infection secondary to obstructed cystic duct

VI. Differential Diagnosis

  1. Typical right upper quadrant and Epigastric Pain presentations
    1. Hepatitis
    2. Hepatic Abscess
    3. Pancreatitis
    4. Gastritis
    5. Peptic Ulcer Disease (perforated or penetrating)
    6. Gastroesophageal Reflux disease
  2. Atypical presentations in the abdominal RUQ or epigastric region
    1. Fitz Hugh-Curtis Syndrome
      1. Gonorrhea or Chlamydia perihepatitis
    2. Pelvic Inflammatory Disease
    3. Appendicitis
    4. Pyelonephritis
  3. Chest conditions with radiation into abdominal RUQ or epigastric region
    1. Right lower lobe Pneumonia
    2. Myocardial Ischemia or Myocardial Infarction

VIII. Findings: Symptoms and Signs

X. Management: Approach

  1. Watchful waiting (expectant management, no intervention) Indications
    1. Asymptomatic Gallstones (incidentally identified on imaging)
    2. Pregnancy and symptomatic Gallstones
  2. Watchful waiting or Cholecystectomy indications
    1. Symptomatic Gallstones without complications (e.g. Biliary Colic)
      1. Symptoms resolve in 50% of patients without surgery
      2. Verhus (2002) Scand J Gastroenterol 37:834-9 [PubMed] (or open in [QxMD Read])
  3. Cholecystectomy indications
    1. Recurrent bililary colic
    2. Acute Cholecystitis
      1. Cholecystectomy within 72 hours of onset
    3. Gallstone Pancreatitis
      1. Cholecystectomy prior to Pancreatitis hospitalization discharge
    4. Gallbladder Calcification (porcelain gallbladder)
      1. Risk of gallbladder cancer
    5. Hemolytic Anemia
      1. Chronic Hemolysis is high risk for formation of black pigmented stones (calcium Bilirubinate Gallstones)
    6. Large Gallstones (>3 cm)
      1. High risk of gallbladder cancer
    7. Pending Bariatric Surgery for morbid Obesity
      1. High risk of symptomatic gallbladder disease related to rapid weight loss
    8. Native american ethnicity
      1. Higher risk of gallbladder cancer
    9. Pending transplant (with immunosuppression)
      1. Chronic immunosuppression risks blunted gallbladder symptoms and increased risk of Ascending Cholangitis
    10. Gallbladder dysmotility and small Gallstones
      1. Increased risk of gallstone Pancreatitis
    11. Pregnancy and recurrent or intractable biliary pain (or associated complications)
      1. Symptomatic management is preferred
      2. However Laparoscopic Cholecystectomy is indicated if uncontrolled, persistent symptoms
    12. Child-Pugh Class A or B Cirrhosis
      1. Laparoscopic Cholecystectomy is indicated for symptomatic Gallstones (despite the increased complication risk)
  4. ERCP and Cholecystectomy indications
    1. Choledocholithiasis
  5. Percutaneous cholecystostomy drainage indications (with delayed Cholecystectomy)
    1. Older or critically ill patients with gallbladder empyema (and associated Sepsis)

XII. Complications: Post-Cholecystectomy

XIII. Course: Asymptomatic Gallstones

  1. Symptoms developing in Cholelithiasis: 2% per year (average)
  2. Symptoms within 5 years of diagnosis: 10%
  3. Symptoms within 10 years of diagnosis: 20%

Images: Related links to external sites (from Google)

Ontology: Cholelithiasis (C0008350)

Definition (MEDLINEPLUS)

Your gallbladder is a pear-shaped organ under your liver. It stores bile, a fluid made by your liver to digest fat. As your stomach and intestines digest food, your gallbladder releases bile through a tube called the common bile duct. The duct connects your gallbladder and liver to your small intestine.

Your gallbladder is most likely to give you trouble if something blocks the flow of bile through the bile ducts. That is usually a gallstone. Gallstones form when substances in bile harden. Gallstone attacks usually happen after you eat. Signs of a gallstone attack may include nausea, vomiting, or pain in the abdomen, back, or just under the right arm.

Gallstones are most common among older adults, women, overweight people, Native Americans and Mexican Americans. The most common treatment is removal of the gallbladder. Fortunately, the gallbladder is an organ that you can live without. Bile has other ways to reach your small intestine.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Definition (MSH) Presence or formation of GALLSTONES in the BILIARY TRACT, usually in the gallbladder (CHOLECYSTOLITHIASIS) or the common bile duct (CHOLEDOCHOLITHIASIS).
Definition (CSP) presence or formation of gallstones in the gallbladder.
Concepts Disease or Syndrome (T047)
MSH D002769
ICD9 574
ICD10 K80
SnomedCT 44900007, 197406002, 197403005, 266474003, 155823008, 197376000, 266541001
English Cholelithiases, Cholelithiasis, BILIARY STONES, CHOLELITHIASIS, GALL STONE, gallstone, Cholelithiasis, NOS, Cholelithiasis NOS, GALLSTONES, cholelith, gallstones, Biliary calculus (disorder), Cholelithiasis NOS (disorder), Calculus biliary, Biliary stones, Gall Stones, Gallstones, Biliary Calculi, Gall Stone, Cholelithiasis [Disease/Finding], Gallstones [Disease/Finding], gallbladder calculus, cholecystolithiasis, gallbladder calculus (diagnosis), cholelithiases, calculus of gallbladder, gallbladder stones, gallstone disease, Gallstone(s), gallbladder stone, Calculus in biliary tract, Stone - biliary, Calculus - biliary, CL - Cholelithiasis, Calculus in biliary tract (disorder), Biliary calculus, cholelithiasis, Gallstone, Biliary calculus, NOS, Gallstone, NOS, Biliary calculus (disorder) [Ambiguous], Stones - gall
French LITHIASE BILIAIRE, Calcul biliaire, Lithiases vésiculaires, Calculs biliaires, CALCULS BILIAIRES, Lithiase biliaire (diagnostic), Lithiase biliaire, Cholélithiase
Spanish COLELITIASIS, CALCULOS BILIARES, Cálculo biliar, Piedras biliares, Piedras en la vesícula biliar, Cholelithiasis, Stones - gall, Gallstones, Calculus - gall bladder, Gallbladder calculus, Cholelithiasis NOS, piedra biliar, lito biliar, colelitiasis, SAI (trastorno), colelitiasis, SAI, colelitiasis, cálculo biliar (concepto no activo), cálculo biliar (trastorno), cálculo biliar, cálculo en la vía biliar (trastorno), cálculo en la vía biliar, Colelitiasis
German CHOLELITHIASIS, Gallensteine, Gallenstein, GALLENSTEINE, Cholelithiasis
Portuguese CALCULOS BILIARES, Cálculos biliares, Cálculo biliar, LITIASE BILIAR, Litíase biliar, Colelitíase
Dutch biliaire steen, galstenen, biliaire stenen, cholelithiase, Cholelithiasis, Galstenen
Italian Calcolo biliare, Calcoli biliari, Colelitiasi
Japanese 胆石, 胆石症, タンセキショウ, タンセキ
Swedish Kolelitiasis
Czech cholelitiáza, Cholelitiáza, Žlučový konkrement, Žlučové konkrementy
Finnish Sappikivitauti
Korean 담석증
Polish Kamica żółciowa
Hungarian Epekövesség, Epekövek, Cholelithiasis, Epekő