Cholelithiasis at a glance- 1

General overview about gall stones, types, clinical features, diagnosis and treatment perspectives

1. Cholelithiasis Suman Raj Baral

2. Incidence In USA or Europe, 80% are cholesterol or mixed stones Cholesterol or mixed stones contain 51-99 % pure cholesterol plus admixture of calcium salts, bile acids, bile pigments and phospholipids Pigment stones contain less than 30% cholesterol

3. Factors forming Gall Stones Lithogenic Bile : Increased biliary cholesterol : Obesity, Cholesterol rich diet, Clofibrate therapy Decreased Bile acids : Primary Biliary Cirrhosis, Impaired EHC of bile acids- Ileal resection , cholestyramine therapy or colestipol (bile acid sequestrants ) Decreased biliary lecithin - MDR-3 gene mutation leads to defective lecithin secretion in bile Nucleation : Pronucleating Vs Anti-nucleating factors- excess pronucleation ( mucin , non mucin glycoprotein,Infection ) or defective anti nucleation (Apo A-I and A-II)

4. Risk Factors Obesity Rapid weight loss First degree relatives Childbearing Multiparity Female Sex Drugs- Ceftriaxone, TPN, post menopausal estrogens Ileal disease, resection or bypass Increasing age

5. Pathogenesis Cholesterol is insoluble in water ( water is a major constituent of bile- 85-95% Bile acid and phospholipids in bile keep cholesterol in solution by the formation of micelles An excess of cholesterol relative to bile acids and phospholipids allows cholesterol to form crystals and such bile is called lithogenic or super saturated bile.

6. Clinical Features Silent Stones(Asymptomatic) Symptomatic Cholelithiasis ( Biliary Colic) Features of Acute Calculus Cholecystitis Pain at right hypochondrium , radiating to tip of right shoulder Vomiting Murphy’s Sign positive

7. Investigations Oral Cholecystography ( Graham Cole test) Oral administration of a radiopaque compound that is absorbed, excreted by the liver and passed into the gall bladder Stones noted on a film as filling defect in a visualized opacified gall bladder However, this test has been replaced by ultrasonography

8. Ultrasonography IOC for acute calculus cholecystitis , chronic cholecystitis and cholelithiasis Operator dependent and may be suboptimal due to excessive body fat and intraluminal bowel gas Can demonstrate- Biliary Calculi, Size of GB and CBD, Thickness of GB wall, inflammation around GB, presence of stones within biliary tree

9. HIDA Scan Technetium -99m labelled derivative of imino-diacetic acid are when injected intravenously, selectively taken up by reticulo -endothelial cells of the liver and excreted into bile. Allows visualization of biliary tree and gall bladder GB visualized within 30 mins of isotope injection in 90 % cases Bowel seen within 1 hour of injection Non-visualization of GB suggestive of acute cholecystitis Helpful in diagnosing bile leaks and iatrogenic biliary obstruction

10. Complications

11. Treatment Cholecystectomy Open VS Laparoscopic Cholecystectomy ( Surgical) MEDICAL THERAPY (?? EFFECTIVENESS)

12. To be continued !!!