I. 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

II. Definitions

  1. Biliary Colic
    1. Transient cystic duct obstruction
  2. Acute Cholecystitis
    1. Persistent obstruction of the cystic duct
  3. Cholelithiasis
    1. Presence or formation of Gallstones
  4. Choledocholithiasis
    1. Calculi in the common bile duct

III. Risks Factors

  1. Classic 5 F's
    1. Female
    2. Forty (age over 40 years)
    3. Fair skinned (Scandinavian)
    4. Family History (first degree relative)
    5. Fat (Obesity with BMI >30)
      1. This applies to children as well
  2. Other risks
    1. Pregnancy
    2. History of ileal disease, resection or bypass
    3. Sickle Cell Anemia (common cause in children)
    4. Medications:
      1. TPN Cholestasis (common cause in children)
      2. Ceftriaxone
      3. Premarin

IV. Pathophysiology

  1. Gall Stones
    1. Composition
      1. Cholesterol stones (70-95%) make up 75% Gallstones
      2. Pigment stones account for 25% of Gallstones
    2. Development
      1. Cholesterol supersaturation
      2. Cholesterol crystals nucleate
      3. Increased by impaired gallbladder immotility
  2. Progression to symptoms
    1. Gallbladder distention (hydrops)
    2. Serosal edema
    3. Infection secondary to obstructed cystic duct

V. Differential Diagnosis

  1. Hepatitis
  2. Hepatic Abscess
  3. Pancreatitis
  4. Gastritis
  5. Peptic Ulcer Disease (perforated or penetrating)
  6. Appendicitis
  7. Fitz Hugh-Curtis Syndrome
    1. Gonorrhea or Chlamydia perihepatitis
  8. Pelvic Inflammatory Disease
  9. Pyelonephritis
  10. Right lower lobe Pneumonia
  11. Pleuritis
  12. Myocardial Ischemia or Myocardial Infarction

VII. Symptoms and Signs

VIII. Management

  1. Asymptomatic Gallstones
    1. No treatment recommended (See course below)
  2. Symptomatic Gallstones (see Biliary Colic)
    1. Consider Cholecystectomy
    2. Consider watchful waiting
      1. Symptoms resolve in 50% of patients without surgery
      2. Verhus (2002) Scand J Gastroenterol 37:834-9

IX. Complications: Post-Cholecystectomy

  1. Bile leak
    1. Typically presents within 3 days of laparoscopic Cholecystectomy
    2. Diagnosis
      1. Ultrasound will show a free fluid collection around the biliary duct
      2. ERCP: Dye extravasates
      3. Ultrasound guided needle aspiration will reveal brown bile (as opposed to post-operative hematoma)
    3. References
      1. Weinstock in Majoewsky (2012) EM:RAP 12(3): 3

X. Course

  1. Symptoms developing per year in Cholelithiasis: 1-4%
  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