Gallstones: Causes, Complications and Treatment

Gallstones: Causes, Complications and Treatment

Gallstones are a condition where stones form in the bile duct system, including:

• Gallbladder stones: Stones located in the gallbladder

• Biliary tract stones: Stones in the liver and the bile ducts outside the liver (common hepatic duct, common bile duct).

Anatomy of the liver ducts – biliary tract:

• Common bile duct ascends to the junction with the cystic duct, which leads from the gallbladder. The part from the junction up is called the common hepatic duct.

• The common hepatic duct runs up to the point where it splits into the left hepatic duct and the right hepatic duct.

• From the left and right hepatic ducts, smaller ducts called intrahepatic bile ducts branch out.

What are stones?

Stones are the deposition and precipitation of substances in bile.

Pathogenesis of gallbladder stones:

• Cholesterol stones (ivory white stones): Due to cholesterol saturation in bile, creating a nucleus from substances such as mucin, bacteria, cell debris, and bile stasis.

• Pigment stones (black/brown stones):

• Black stones: Due to hemolysis, cirrhosis,…

• Brown stones: Due to bile duct infection (E. coli secretes enzymes that cause direct bilirubin to be converted to indirect bilirubin, which precipitates with calcium).

• Mixed stones: A combination of both cholesterol stones and pigment stones.

Causes of biliary tract stones:

• Primary causes:

• Bile duct infection (E. coli)

• Bile stasis:

• Bile duct stricture (congenital, post-surgical, chronic inflammation)

• Vater’s papilla stricture

• Tumor

• Secondary stones

• Secondary causes: From the gallbladder.

Risk factors:

• Age >= 40

• Female gender

• Multiple pregnancies, childbirth

• Obesity

• Diabetes

• Cirrhosis, bile duct resection

• Hemolytic disorders, ileal resection

• 4F: Female, Forty, Fat, Fetal

Complications:

• Severe:

• Bile duct infection

• Suppurative cholangitis

• Bile duct abscess

• Liver abscess

• Other:

• Coagulation disorders

• Sepsis, septic shock

• Biliary bleeding

• Bile leakage into the peritoneum, bile peritonitis

• Acute pancreatitis

• Acute kidney failure, hepatorenal syndrome

Clinical manifestations:

• >50% are asymptomatic

• Biliary colic: Related to meals, colicky pain, epigastric/right hypochondrial pain radiating to the back, shoulder.

• Jaundice, icterus: Dark urine, pale stools.

• Hepatomegaly, cholecystectomy

• Fever, chills

• Cholangitis: Charcot’s triad (right upper quadrant pain, fever, jaundice), Reynold’s pentad (adding altered mental status, hypotension).

• Acute pancreatitis

Diagnosis:

• Clinical laboratory tests:

• Biochemical tests: Increased serum bilirubin, alkaline phosphatase, white blood cells, serum amylase, urine amylase, AST, ALT.

• Ultrasound: Safe, inexpensive, fast, detects stones in the common bile duct, biliary dilation.

• CT Scan: Higher sensitivity and specificity than ultrasound, detects stones in the common bile duct and other conditions.

• Magnetic resonance cholangiopancreatography (MRCP): Highest sensitivity and specificity, non-invasive.

• Endoscopic retrograde cholangiopancreatography (ERCP): Invasive, used for both diagnosis and treatment.

• Endoscopic ultrasound (EUS): Less invasive, no need to place cannula through the Vater’s papilla.

• Diagnostic criteria:

• Suspected: Group A + B or A + C

• Confirmed: Group A + B + C

• Group A: Signs of systemic inflammation (fever, CRP increased, white blood cell count increased/decreased).

• Group B: Bile duct obstruction (jaundice, abnormal liver function tests).

• Group C: Imaging studies (gallbladder dilation, bile duct obstruction).

• Disease staging:

• Stage III (severe): Acute cholangitis with dysfunction of one or more organs (heart, lungs, kidneys).

• Stage II: Acute cholangitis with 2 of the factors (white blood cell count increased/decreased, high fever, advanced age, increased bilirubin, decreased albumin).

• Stage I (mild): Not stage II or III.

Treatment:

• Stage I: Antibiotics, intravenous fluids, medical management.

• Stage II: Drainage, antibiotics, medical management, medical management.

• Stage III: Emergency treatment: Drainage, organ function adjustment, antibiotics, medical management.

Note: Early and timely treatment is crucial to prevent serious complications.