Cholelithiasis

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

COMPLICATION:

In the gallbladder:

1. Silent stones
2. Chronic cholecystitis
3. Acute cholecystitis
4. Gangrene
5. Perforation
6. Empyema
7. Mucocele
8. Carcinoma
9. Soma
10. tostatinoma(most common)

In the bile ducts:

1. Obstructive jaundice
2. Cholangitis
3. Acut
4. e pancreatitis

• In the intestine: Acute intestinal obstruction (gallstone ileus)A gall stone gets impacted most commonly in Ampulla of vater of common bile duct

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

Contraindications for medical management are:

• Radio-opaque concretions
• Gallstones >20mm in diameter
• Non opacified gall bladder
• Acute &/or chronic cholecystitis
• Complications of gallstones
• Poor patient compliance