Cholelithiasis

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Cholelithiasis, commonly known as gallstones, refers to the formation of solid deposits within the gallbladder. The gallbladder is a small, pear-shaped organ located beneath the liver. Its main function is to store and concentrate bile, which is produced by the liver and assists in the digestion of fats.

Gallstones develop when there is an imbalance in the constituents of the bile, leading to the accumulation of substances such as cholesterol, bilirubin, calcium salts, and other particles. These substances can harden and form small, pebble-like formations ranging in size from grains of sand to larger marble-like structures.

There are two primary types of gallstones: cholesterol stones and pigment stones.

• Cholesterol stones, as the name suggests, are composed predominantly of cholesterol. Increased levels of cholesterol in the bile can result from factors such as obesity, a high-fat diet, rapid weight loss, or an imbalance in certain substances produced by the liver.

• Pigment stones are formed when there is an excess of bilirubin, a yellowish pigment that results from the breakdown of red blood cells. These stones are more commonly associated with various liver conditions, such as cirrhosis, biliary tract infections, or blood disorders.

• Gallbladder stasis: When the gallbladder fails to empty its contents properly, the bile becomes concentrated, leading to the formation of gallstones.

• Excessive cholesterol: High levels of cholesterol in the bile can cause the formation of cholesterol stones, which are the most common type of gallstones.

• Bilirubin imbalance: When there is excessive bilirubin production or inefficient bilirubin metabolism, it can result in the formation of pigment stones, which are made up of bilirubin.

• Genetics: There is evidence to suggest that gallstone formation has a hereditary component, indicating a genetic predisposition.

• Obesity: Being overweight or obese increases the risk of developing gallstones due to altered bile metabolism and increased cholesterol production.

• Rapid weight loss: Losing weight too quickly, especially through crash diets or bariatric surgery, can disrupt the balance of bile salts and cholesterol, leading to gallstone formation.

• Gender and age: Women, especially those who have experienced multiple pregnancies, are more prone to gallstone formation. Furthermore, the risk of gallstones increases with age.

• Medical conditions: Certain medical conditions, including metabolic syndrome, diabetes mellitus, Crohn's disease, and cirrhosis, are associated with a higher risk of developing gallstones.

One of the primary contributors to gallstone formation is an imbalance in the bile composition, typically caused by an increased concentration of cholesterol or bilirubin. These substances are normally soluble in bile but can become supersaturated and form solid particles under certain conditions.
An excess of cholesterol in bile, known as cholesterol supersaturation, is the most common pathogenic factor for gallstone formation. This occurs when the liver excretes more cholesterol into the bile than can be dissolved by the available bile acids. Various factors, such as obesity, rapid weight loss, certain medications, and hormonal imbalances, can disrupt the cholesterol-bile acid balance, leading to the precipitation of cholesterol crystals. Over time, these crystals can aggregate and form larger gallstones.

1. Gender: Studies have shown that women are more prone to developing gallstones than men. Hormonal factors, including the influence of oestrogen, play a crucial role in increasing the risk. Pregnancy, hormone replacement therapy, and the use of birth control pills can further elevate the risk among women
2. Age: Cholelithiasis is more prevalent among individuals over 40 years of age. As people age, the ability of the gallbladder to efficiently empty bile decreases, increasing the chances of gallstone formation. Older individuals also tend to have higher levels of cholesterol and reduced gallbladder motility, further contributing to the risk.
3. Obesity: Being overweight or obese significantly increases the risk of gallstone formation. Excess body weight leads to higher cholesterol production, which can contribute to the accumulation of cholesterol-based gallstones. Moreover, obesity can impact various metabolic processes, such as impairing the contractile function of the gallbladder, thereby promoting gallstone development.
4. Rapid weight loss or dieting: Sudden and significant weight loss, often associated with crash dieting or bariatric surgery, can predispose individuals to cholelithiasis. Rapid weight loss leads to a substantial increase in the amount of cholesterol secreted by the liver into the bile, exceeding the gallbladder's capacity to dissolve it. Consequently, this excess cholesterol solidifies into gallstones.
5. Genetics and family history: A family history of gallstones is indicative of an increased susceptibility to cholelithiasis. Certain genetic factors influence the composition of bile and its propensity to form stones. Additionally, genetic conditions like sickle cell anaemia and hereditary haemolytic disorders may raise the risk of pigmented gallstones.
6. Certain medical conditions: Several medical conditions can raise the risk of developing gallstones. These include diabetes, liver cirrhosis, Crohn's disease, metabolic syndrome, and other conditions that affect bile metabolism, cholesterol levels, or gallbladder function. Moreover, prolonged use of medications like fibrates or octreotide can also increase the risk.
7. Ethnicity: Certain ethnic groups, such as Native Americans and Hispanics, demonstrate a higher prevalence of gallstone formation. The underlying reasons for these disparities are not entirely clear, but they may involve a combination of cultural, genetic, and dietary factors.
8. Lifestyle and diet: Sedentary lifestyles, lack of regular physical activity, and diets high in cholesterol, saturated fats, and refined carbohydrates can contribute to the formation of gallstones. Conversely, diets rich in fibre, fruits, vegetables, and whole grains have been associated with a lower risk.

1. Abdominal pain: The most common symptom of cholelithiasis is acute or chronic abdominal pain. This pain typically occurs in the upper right quadrant of the abdomen, under the rib cage. It may be intermittent or constant and can radiate to the back or right shoulder blade. The intensity of the pain can range from mild discomfort to severe, sharp cramping.
2. Nausea and vomiting: Many individuals with gallstones experience episodes of nausea and vomiting. This can be triggered by the presence of gallstones that obstruct the bile flow, leading to digestive disturbances. Nausea and vomiting may be accompanied by bloating and a feeling of fullness after eating.
3. Jaundice: When a gallstone obstructs the bile duct, it can cause a buildup of bilirubin, a yellow pigment produced during the breakdown of red blood cells. This buildup can result in jaundice, which is characterized by yellowing of the skin, eyes, and mucous membranes. Dark urine and pale stools may also occur due to the impaired excretion of bilirubin.
4. Fever and chills: In some cases, if a gallstone obstructs the bile duct and leads to an infection, individuals may experience fever and chills. This can indicate the presence of a more severe condition called acute cholecystitis, which requires immediate medical attention.
5. Indigestion and bloating: Difficulty digesting fatty foods, flatulence, and bloating are common symptoms associated with cholelithiasis. This occurs when the gallstones interfere with the proper release and transport of bile, which aids in the digestion of fats.
6. Back pain: Gallstones can sometimes cause referred pain to the back, usually radiating from the upper abdomen to the back or right shoulder blade. This pain may be mistaken for other conditions, leading to delayed diagnosis.
7. Intolerance to certain foods: Individuals with cholelithiasis may experience discomfort or intolerance to certain foods, especially those high in fat. Symptoms can include diarrhoea, cramping, and increased pain after consuming fatty meals.

1. History and Physical Examination: inquire about the patient's symptoms, such as upper abdominal pain, nausea, vomiting, or jaundice. The physical examination may reveal tenderness or a palpable mass in the right upper abdominal quadrant (RUQ).
2. Ultrasound: ultrasound is the primary diagnostic imaging modality used to identify gallstones and assess their characteristics. It is safe, non-invasive, cost-effective, and readily available. It can used to detect the presence, location, size, and number of gallstones, as well as evaluate the gallbladder's wall thickness and any associated complications.
3. Liver Function Tests (LFTs): Liver function tests help assess the overall function and health of the liver. In cholelithiasis, LFTs are valuable in identifying any liver dysfunction, as gallstones can cause obstructive jaundice or inflammation of the liver. Elevated levels of liver enzymes, bilirubin, or alkaline phosphatase may indicate associated complications like choledocholithiasis or cholecystitis.
4. Endoscopic Retrograde Cholangiopancreatography (ERCP): ERCP is a diagnostic and therapeutic procedure used when common bile duct (CBD) stones are suspected. It involves the insertion of an endoscope through the mouth into the duodenum to visualize the biliary tree. ERCP allows direct visualization of CBD stones and their subsequent removal using specialized instruments.
5. Magnetic Resonance Cholangiopancreatography (MRCP): MRCP is a non-invasive imaging technique that combines magnetic resonance imaging (MRI) with cholangiography. It provides detailed images of the biliary tree and can effectively visualize gallstones, CBD stones, and other biliary abnormalities without the need for invasive procedures.

Symptom Management

In cases where the gallstones are asymptomatic or causing mild symptoms, management may focus on controlling the symptoms rather than removing the stones. Pain management medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can be prescribed to alleviate discomfort during episodes of pain.

Surgical Interventions

When gallstones are causing severe symptoms or complications, surgical interventions become necessary. The most common surgical procedures for cholelithiasis are:

• Laparoscopic Cholecystectomy: Laparoscopic cholecystectomy is a minimally invasive surgical procedure that involves the removal of the gallbladder. This procedure is highly effective for symptomatic gallstones and is associated with shorter recovery times, less pain, and minimal scarring compared to open surgery.

• Endoscopic Retrograde Cholangiopancreatography (ERCP): ERCP is a procedure used to remove gallstones that have migrated into the bile ducts. During this procedure, an endoscope is passed through the mouth and into the small intestine, where a wire is used to remove or break down the stones.

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