Referat

Gallstone

ADITIYA SETYORINI
1510029032
Background
Cholesterol Bilirubin Bile acid

Impaired
metabolism

gallstone

Burden to Serious
health system outcomes

Galldbaldder
Pancreatitis
cancer

(Reshetnyak, 2012)
Definition
Gallstone disease (GD) (cholelithiasis) is a chronic recurrent
hepatobiliary disease, the basis for which is the impaired
metabolism of cholesterol, bilirubin and bile acids, which is
characterized by the formation of gallstones in the hepatic bile duct,
common bile duct, or gallbladder. The first and most common type
(representing about 75% of cases) are cholesterol stones
(Reshetnyak, 2012).
Epidemiology
Gallstones constitute a significant health problem in
developed societies, affecting 10% to 15% of the adult
population, meaning 20 to 25 million Americans have
(or will have) gallstones (Stinton & Shaffer, 2012).

Western countries :7.9% in men to 16.6% in women.

Asians : approximately 3% to 15%,
Africans is nearly non-existent (less than 5%)
China : from 4.21% to 11% (Reshetnyak, 2012)
Risk factors for gallstone formation

(Stinton & Shaffer, 2012 )

(Stinton & Shaffer, 2012 )
(Marschall & Einarsson, 2007)
(Bansal, Akhtar, & Bansal, 2014)
(Bansal, Akhtar, & Bansal, 2014)
(Bansal, Akhtar, & Bansal, 2014)
Major components of cholesterol
metabolism and bile formation

(Marschall & Einarsson, 2007)

Pathophysiology

(Marschall & Einarsson, 2007)

 For the formation of cholesterol gall bladder
stones, three mechanisms are of major
importance (Marschall & Einarsson, 2007) :
(i) cholesterol, supersaturation of bile;
(ii) gallbladder hypomotility;
(iii) kinetic, pro-nucleating protein factors
Clinical aspects of gallstone disease
1. Asymptomatic/Silent gallstones
up to 80%
2. Symptomatic gallstones disease
3. Functional (acalculous) gallbladder disease
(Stinton & Shaffer, 2012)

The majority (60-80%) remain asymptomatic

throughout a patients' lifetime and only manifest
on imaging done for other reasons. The remaining
20-40% of gallstones are either symptomatic or
symptomatic with advanced complications
(Luzietti, 2015)
Gallstone disease may be thought of as having the following 4 stages:

Lithogenic state, in which conditions favor gallstone

formation
Asymptomatic gallstones
Symptomatic gallstones, characterized by episodes of
biliary colic
Complicated cholelithiasis
Clinical maifestation
biliary pain relative to defined characteristics (e.g.,
episodic, steady, severe pain located in the upper
abdomen and lasting more than 30 minutes) and
some accompanying features (nausea and vomiting;
radiating through to the back), certain foods
(particularly those high in fat) typically provoke
symptoms , Pain that is constant; not relieved by
emesis, antacids, defecation, flatus, or positional
changes, Nonspecific symptoms (eg, indigestion,
dyspepsia, belching, or bloating)
(Stinton & Shaffer, 2012 ; Luzietti, 2015 ; Heuman,
2016)
(Alam & Demehri, 2015)
(Alam & Demehri, 2015)
Physical exam
discomfort may be elicited by deep palpation in the RUQ.
A positive Murphy sign usually indicates more severe disease
(cholecystitis).
Typically, however, vital signs and physical exam are usually
normal in patients with cholelithiasis.
Fever, tachycardia, and hypotension should alert to more
advanced disease (cholecystitis and cholangitis) (Luzietti, 2015)
.
patients at high risk for experiencing biliary
complications:
(1) Large gallstones (>3 cm)
(2) Sickle cell disease
(3) Solid organ transplantation
(4) Abdominal surgery, performed for other reasons
(Stinton & Shaffer, 2012 )
Diagnosis

Patients with uncomplicated cholelithiasis or

simple biliary colic typically have normal
laboratory test results; laboratory studies are
generally not necessary unless complications are
suspected. Blood tests, when indicated, may
include the following (Heuman, 2016):
Complete blood count (CBC) with differential
Liver function panel
Amylase
Lipase
Imaging modalities that may be useful include the
following (Heuman, 2016) :
Abdominal radiography (upright and supine) Used primarily to
exclude other causes of abdominal pain (eg, intestinal obstruction)
Ultrasonography The procedure of choice in suspected gallbladder or
biliary disease
Endoscopic ultrasonography (EUS) An accurate and relatively
noninvasive means of identifying stones in the distal CBD
Laparoscopic ultrasonography Promising as a potential method for
bile duct imaging during laparoscopic cholecystectomy
Computed tomography (CT) More expensive and less sensitive than
ultrasonography for detecting gallbladder stones, but superior for
demonstrating stones in the distal CBD
Magnetic resonance imaging (MRI) with magnetic resonance
cholangiopancreatography (MRCP) Usually reserved for cases in
which choledocholithiasis is suspected
Scintigraphy Highly accurate for the diagnosis of cystic duct
obstruction
Endoscopic retrograde cholangiopancreatography (ERCP)
Percutaneous transhepatic cholangiography (PTC)
Treament
The treatment of cholelithiasis is symptomatic
and chiefly aims at removing the stones from the
gallbladder or bile ducts. When the cause of the
disease is known, the conditions resulting in
cholelithiasis, such as hemolytic anemia, obesity,
diabetes mellitus, etc, are treated (Reshetnyak,
2012).
surgical and medical treatments for cholelithiasis are
equally used today. The basic treatments for GD are
(Reshetnyak, 2012) :
(1) cavitary cholecystectomy endoscopic cholecystectomy
(2) litholytic therapy (LT)
(3) extracorporeal shock wave lithotripsy (ESWL);
(4) extracorporeal shock wave lithotripsy + Litholytic
therapy
(5) percutaneous transhepatic LT.
For successful litholytic therapy, definite criteria should
be met for selection of patients with cholelithiasis
(Reshetnyak, 2012) :

(1) the stone should be cholesterol or mixed

(2) the size of the stones should not be greater
than 1.5 cm
(3)the gallbladder should fully preserve its
function and be packed with stone not more
than of the fasting volume; the cystic duct
and common bile duct should preserve their
patency; enterohepatic circulation of bile
enterohepatic circulation of bile acids should
be preserved.
When selecting the patients correctly, the efficiency of
litholytic therapy with UDCA is as high as 60%-90%:
(1) in the presence of cholesterol small stone, it is up to
90%; (2) with single mixed gallstones 1 cm in diameter,
it is up to 75%
(3) with multiple mixed gallstones with the maximum
diameter of < 1 cm, it is up to 60%.
Contact litholysis
Lithotripsy is considered successful if stones less than 5
mm in diameter can be fragmented. ESWL yields good
results when minor (< 20 mm) single stones are
shattered.
Criteria for selection of patients for lithotripsy are as
follows (Reshetnyak, 2012) :
1. single radiolucent cholesterol stones not more single
radiolucent cholesterol stones not more than 3 cm in
diameter
2. not multiple radiolucent stones (not more than 3) 1-1.5 cm
in diameter
3. the volume of stones is < 1/2 of that of the gallbladder
4. a functioning gallbladder
5. normal bile duct patency

contraindications to ESWL;
the presence of coagulopathy or anticoagulant therapy;
the presence of cavitary mass along the course of a shock
wave. Approximately 20% of patients with GD meet the
criteria for ESWL.
Management

The treatment of gallstones depends upon the stage of the

disease, as follows (Heuman, 2016) :
Lithogenic state Interventions are currently limited to
a few special circumstances
Asymptomatic gallstones Expectant management
Symptomatic gallstones Usually, definitive surgical
intervention (eg, cholecystectomy), though medical
dissolution may be considered in some cases
Medical treatments, used individually or in combination,
include the following:
Oral bile salt therapy (ursodeoxycholic acid)
Contact dissolution
Extracorporeal shockwave lithotripsy
Cholecystectomy for asymptomatic gallstones may be
indicated in the following patients (Heuman, 2016) :

Those with large (>2 cm) gallstones

Those who have a nonfunctional or calcified
(porcelain) gallbladder on imaging studies and are
at high risk of gallbladder carcinoma
Those with spinal cord injuries or sensory
neuropathies affecting the abdomen
Those with sickle cell anemia in whom the
distinction between painful crisis and cholecystitis
may be difficult
Patients with the following risk factors for complications
of gallstones may be offered elective cholecystectomy,
even if they have asymptomatic gallstones (Heuman,
2016) :
Cirrhosis
Portal hypertension
Children
Transplant candidates
Diabetes with minor symptoms

Surgical interventions to be considered include the

following:
Cholecystectomy (open or laparoscopic)
Cholecystostomy
Endoscopic sphincterotomy
 Therapy

Today, the treatment of choice of symptomatic gallstone disease is

laparoscopic cholecystectomy

Oral bile acid litholysis with chenodeoxycholic acid and/or

ursodeoxycholic acid (UDCA) have a very high recurrence rate

intrahepatic cholelithiasis in patients with MDR3 aberrations may

profit from treatment with UDCA. Extracorporeal shock-wave
lithotrypsi, combined with oral bile acid mostly abandoned because
of the high risk of stone Recurrence. (Marschall & Einarsson, 2007).
Complications
cholecystitis
cholangitis
biliary pancreatitis
Persistent pain, fever, and jaundice indicating
acute
cholangitis are known as Charcots Triad.
Gallbladder cancer is rare but closely related to
gallbladder stones (Marschall & Einarsson,
2007)
Prevention
life-style changes,
Oral UDCA during weight-loss prevented
cholesterol gallstone formation in man
Stimulation of nuclear receptors regulation
cholesterol metabolism and secretion, as shown
by the efficient prevention with synthetic FXR
agonists in mice
 Bibliography

Alam, H. B., & Demehri, F. R. (2015). Evaluation and Management of Gallstone-Related Diseases in Non-
Pregnant Adult. Guidelines for Clinical Care .

Bansal, A., Akhtar, M., & Bansal, A. K. (2014). A clinical study: prevalence and management of cholelithiasis.
International Surgery Journal .

Heuman, D. M. (2016, April 14). Gallstones (Cholelithiasis).

Luzietti. (2015). Dipetik 11 1, 2016, dari University of Connecticut Health center:

http://fitsweb.uchc.edu/student/selectives/Luzietti/Gallbladder_cholelithiasis.htm

Marschall, H.-U., & Einarsson, C. (2007). Gallstone disease. Journal of inetrnal medicine .

Reshetnyak, V. I. (2012). World J Hepatol , 4(2): 18-34 .

Reshetnyak, V. I. (2012). Concept of the pathogenesis and treatment of cholelithiasis. World Journal of
Hepatology , 4(2): 18-34.

Stinton, L. M., & Shaffer, E. A. (2012). Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer. Gut
and Liver , pp. 172-187.