Cholelithiasis

4th year pathology

1. Cholelithiasis Presentation by Dr. Hassan Yar Pathology Dept. GMC

2. Outlines Understanding gallstones and it’s types
Pathophysiology and morphology Clinical features Diagnosis
Complications

3. Introduction to gallstones Gallstones refer to concretions made in gallbladder out of bile components. The term Cholelithiasis may refer to presence of gallstones or disease caused by it. It is one of the leading cause of general and Hepatobiliary surgeries.

4. Bile physiology Bile is a greenish yellow aqueous solution produced and secreted by the liver.
Bile flows into the gallbladder (from liver via hepatic ducts), where it is concentrated and stored. The hormone cholecystokinin (CCK), regulates it’s flow/secretion. Bile acids represent the primary pathway for cholesterol catabolism. Two main functions: Excretion of hepatic metabolites
Emulsification of fat

5. Components of bile Bile salts/acids (67%), potent “digestive surfactants” Phospholipids (22%) Proteins (4.5%), free CH (4%), conjugated bilirubin (0.3%) Water, electrolytes, bicarbonates

6. Types of gallstones There are two main types of gallstones: Cholesterol gallstones Pigment gallstones A minor subset of Mixed gallstones is also present.

7. Cholesterol stones 75% of the cases Primarily in lumen
Contains CH(50-100%), calcium carbonate, phosphate and bilirubin
Radiolucent If calcium carbonate is not present in sufficient amount

8. Pigment stones Black pigment stones Sign of chronic EHA
Calcium + UCB = calcium bilirubinate (black) Radiopaque Brown pigment stones Sign of infection in the CBD
Asians Soapy fatty acid residue
Radiolucent

9. Morphology CH stones Pale yellow to gray or black
Obvious and firm Faceted/rough Pigment stones Black Stones: Small, fragile, numerous Brown Stones: Single or few Soft, greasy and soaplike

10. Pathogenesis There are 3 main concepts: Supersaturation (of bile with CH): either by ⬆️CH or ⬇️bile salts/acids and lecithin ⬆️ Bilirubin: esp. in hemolytic anemia or infections, causing UCB to form precipitates with bile pigments 3. Stasis coupled with ⬆️ mucin secretion

11. Risk factors

12. Risk factors Predisposing factors for cholesterol stones include conditions which imbalances equilibrium of cholesterol metabolism e.g. age, gender females >40yrs OCPs
Obesity
Rapid weight loss On the other hand, pigment stones form due to presence of unconjugated bilirubin e.g. Hemolytic anemias Infections
Cirrhosis
Pathologies of biliary tree

13. Clinical features Mostly asymptomatic (depends on the causative pathology) Spasmodic pain RUQ/Epigastrium
Fever
Jaundice
Nausea/Vomiting Bloating Indigestion

14. Diagnosis Lab investigations are aimed at diagnosing the underlying pathology and includes: CBC
LFTs
Amylase/Lipase The definitive diagnosis of gallstones is usually reached by ultrasonography and others include a mix radiological and endoscopic procedures. ERCP (endoscopic retrograde cholangiopancreatography) MRCP (magnetic resonance cholangiopancreatography)
PTC (percutaneous transhepatic cholangiography)

15. Complications Cholecystitis
Gallbladder empyema
Obstruction of biliary/pancreatic ducts
Perforation due to long standing obstruction
Gallstone ileus (intestinal obstruction) Adenocarcinoma of gall bladder

16. Treatment/Prevention Life style changes: Preventing cholelithiasis Regular exercise Coffee consumption Avoiding lithogenic diet
Maintain a healthy weight Medical management: mostly in asymptomatic cases Ursodeoxycholic acid (xray –ve stones) Extracorporeal shockwave lithotripsy (particularly for noncalcified cholesterol gallstones) Surgical management: symptomatic cases Cholecystectomy (open or laproscopic)