4.

Gallstones
In this episode, Dr. Parveen Boora discusses gallstones.
Topics covered include:
epidemiology of gallstone disease
pathogenesis of gallstones
pathiophysiology and treatment of biliary
choledocholithasis and cholangitis
history and physical exam findings
investigations
laparoscopic cholecystectomy procedure

colic,

cholecystitis,

Terms

cholelithiasis = presence of gallstones in gallbladder

biliary colic = pain caused by gallbladder contracting against an
obstructed cystic duct
cholecystitis = inflammation of gallbladder
choledocholithiasis = inflammation and infection of common bile duct

Introduction

common condition
approximately 20% of women and 5-10% of men will have
cholelithiasis by age 50
rule of thumb is 20% of people have gallstones, 20% of those will
have symptoms and 20% of those will have cholecystitis or a more
serious complication

Copyright The Surgery 101 team (www. surgery101.org) 2012

Types of Gallstones

cholesterol stones
pigment stones
mixed stones most common
best way to determine type is U/S imaging

Risk Factors

female
obesity
over age 40
multiparty
aboriginal people have high incidence

Gallstone Symptoms

bilary colic
most common condition
occurs when stones obstruct normal flow of bile
usually associated with URQ pain that radiates to back or
right scapula
pain usually occurs after high fat meal
pain typically lasts few hours before subsiding
physical exam is afebrile and stable vital signs with
tenderness on abdominal palpation
labs will typically be normal
if bilary colic is suspected, order U/S
urgent surgical consult not required but out-patient
discussion of cholecystectomy should be arranged
pain management required, Buscopan most commonly
prescribed
only resolution is eventual removal of gallbladder

Copyright The Surgery 101 team (www. surgery101.org) 2012

cholecystitis
inflammation of gallbladder due to obstruction of cystic
duct by gallstones
gallbladder becomes swollen and edematous; if
prolonged, gallbladder necrosis can result
pain typically lasts in excess of 6 hours
presence of fever and Murphys sign are typical findings
labs may or may not show elevated WBC, ALT, ALP,
bilirubin
U/S will show thick-walled gallbladder with possible fluid
if symptoms less than 48-72 hours, best treatment is early
cholecystectomy
if symptoms greater than 72 hours, antibiotics and pain
control first course of action followed by eventual
cholecystectomy
exceptional situations
patients who present with severe
cholecystitis high fever and greatly
elevated WBC count; should be
operated on immediately
if emphasematous cholecystitis is
present, urgent surgery is warranted
if patient diagnosed with acalculous
cholecystitis, emergency surgery is
preferred treatment

Cholecystectomy

indicated in any individual with symptomatic gallstone disease

majority done by laparoscopy; 5% of elective cases and 30% of
emergency cases converted to open procedure
converted to open procedure when anatomy unclear, or there is
uncontrolled bleeding or contamination

Copyright The Surgery 101 team (www. surgery101.org) 2012

choledolithiasis
when gallstone makes way through cystic duct and is in
the common bile duct
two serious complications can occur, cholangitis and
pancreatitis
cholangitis
findings include fever, jaundice, RUQ
pain, hypotension, decreased level of
consciousness
lab findings will show elevated WBC,
ALT, ALP, bilirubin
U/S can confirm diagnosis
immediate treatment with antibiotics
required with eventual cholecystectomy

Summary

Gallstones are very common, but only a minority ever produce

symptoms.
Gallstones are formed as a result of an imbalance in the usual
concentrations of bile salts, lecithin and cholesterol in bile.
Biliary colic is right upper quadrant pain resulting from the gallbladder
contracting against a cystic duct obstructed by gallstones. Fever and
jaundice are absent and the pain subsides within 6 hours.
Cholecystitis is the result of obstruction of the outflow of bile from the
gallbladder, usually by a gallstone, that is prolonged, resulting in
inflammation and infection. The pain persists beyond 6 hours and is
typically accompanied by fever and leukocytosis. Antibiotic treatment
and cholecystectomy is the preferred treatment.
Cholangitis is the infection of the common bile duct, usually caused
by an obstructing gallstone. Charcots triad (fever, jaundice and right
upper quadrant pain) are the classic findings. Cholangitis can be life
threatening
and
antibiotics,
resuscitation
and
emergent
decompression of the common bile duct, usually by ERCP, are the
treatment.
Copyright The Surgery 101 team (www. surgery101.org) 2012