Image Based Question-71144

A 47-year-old obese woman presented with on and off epigastric pain for 4 months. The pain was dull in nature and aggravated by fatty meals. Physical examination was essentially normal.

Laboratory investigations showed normal liver function and white cell count. An abdominal x-ray was performed as a routine initial investigation.What can be the most possible diagnosis?

A. Gall Stone

B. Kidney Stone

C. Hepatic Calcification

D. Renal Tuberculosis

Show Answer

Correct Answer » A Explanation

Ans:A. Gall Stone

Image shows:Abdominal radiograph showing faceted calcification in the right upper quadrant suggestive of gallstone (arrow).

CHOLELITHIASIS

PATHOGENESIS:

Lithogenic bile Normal ratio of bile acids : cholesterol = 25:1 critical ratio < 13 : 1 Increased cholesterol Decreased bile salts Decreased entero hepatic circulation

Stasis Prolonged TPN Fasting Pregnancy Drugs- octreotide, estrogen therapy Burns Vagotomy

PREDISPOSING FACTOR:

Cholesterol stones

Old age Female sex, pregnancy Obesity, Hyperlipidemia Rapid weight reduction Drugs: OCPs, Estrogen, Clofibrate, Cholestyramine Gall bladder hypomotility (TPN, fasting, pregnancy, octreotide) Diabetes mellitus Spinal cord injury High calorie diet, High fat diet Chronic hemolytic disease (sickle cell anemia, spherocytosis) Ileal resection or disease Cystic fibrosis Chronic liver disease Crohn’s disease Prolonged parenteral nutrition Prematurity with complicated medical or surgical course Prolonged fasting or rapid weight reduction Treatment of childhood cancer Abdominal surgery Pregnancy

Pigment stones

Black pigment	Brown pigment
Insoluble bilirubin with calcium phosphate and calcium bicarbonate Usually in sterile GB Small, multiple and hard Haemolytic states – hereditary spherocytosis, sickle cell disease, thalassemia, malaria Mechanical heart valves	Calcium bilirubinate, calcium palmitate, calcium stearate and cholesterol Formed in biliary tree Commonly due to infection (MC-E.coli) Presence of stents Parasites (Ascaris lumbricoides and Clonorchis sinensis)

Clinical Features:

• 5 Fs: Flat, Fertile, Flatulent, Female, Forty

• Commonest type of gall stone is mixed

• Childhood cholelithiasis is seen in Neimann Pick’s disease

• Illeo cecal junction is the most common site of intestinal obstruction caused by a gall stone

• Biliary colic with periodicity, severe within hours after meal (commonest presentation)

• The Gall stone pain is referred to the shoulder through C3-05

• Dyspepsia is a common symptom

• Cholesterol stones are mostly radio-lucent

• Gall stones contains Cholestrol, Phosphate, Carbonate

• Pigment stones are mostly radio opaque

• No resolution of symptoms, fever and leucocytosis Acute cholecystitis

• The commonest site of obstruction in Gall stone ileus is Distal ileum

• Centre of the stone may contain radiolucent gas which is either triradiate (Mercedes Benz sign) or biradiate (Seagull sign)

• GB may be filled with toothpaste like material(calcium carbonate + phosphate) – limey gall bladder

• Bouveret’s syndrome or gallstone ileus- a large stone may erode directly into an adjacent loop of small bowel causing intestinal obstruction.

Management:

Management

• Investigation of choice – USG

• Best investigation for diagnosis of ampullary gall stone with obstructive jaundice is ERCP

• 10% Percent of gall stones are radio opaque

• Prophylactic cholecystectomy can be considered in

• Diabetic patients

• Congenital haemolytic anemia

• Patients undergoing Bariatric surgery

• The treatment priority should focus on relief of obstruction and not on gall bladder and its fistulous communication

• Multiple Gall stones & 8 mm dilation with 4 stones in CBD, best treatment modalities are Cholecystectomy with choledocholithotomy at same setting

• Elective open cholecystectomy for cholelithiasis is the surgical procedures is considered to have a clean-contaminated wound

• Cholecystectomy if it is asymptomatic but develops biliary colic

• Symptomatic gallstones are the main indication for cholecystectomy.

• Absolute contraindications for the procedure are uncontrolled coagulopathy and end-stage liver disease.

• Medical therapy for gall stone dissolution utilizes two bile acids

• Ursodeoxycholic acid (UDCA)

• Chenodeoxycholic acid (CDCA)

• For patients with serious comorbid conditions not responding to conservative treatment – percutaneous cholecystostomy is performed under USG control, which will rapidly relieve the symptoms. A subsequent cholecystectomy is usually required

• Recurrent attacks of cholelithiasis, U/S examination shows a dilated CBD of 1 cm is best treated with ERCP

• Surgery: lap cholecystectomy or open cholecystectomy through right subcostal Kocher’s incision

• Open cholecystectomy for cholelithiasis is considered a clean contaminated wound

• Indication for medical treatment in gall stone is stone

• size less than 15mm,

• Radioluscent stones,

• Functioning gall bladder,

• Non acute symptoms