Management of gallstones

Many patients with gallstones can be managed expectantly. Generally, only persons with symptoms related to the presence of gallstones (e.g., steady, nonparoxysmal pain lasting four to six hours located in the upper abdomen) or complications (such as acute cholecystitis or gallstone pancreatitis) warrant surgical intervention. Biliary pain is alleviated by cholecystectomy in the majority of cases. Laparoscopic cholecystectomy is considered the most cost-effective management strategy in the treatment of symptomatic gallstones. Medical management strategies are mostly palliative and are not widely supported. Patients with longer-lasting biliary pain, in combination with abdominal tenderness, fever, and/or leukocytosis, require an ultrasound evaluation to help establish a diagnosis of acute cholecystitis. Once a patient is diagnosed, having cholecystectomy early in the course of the disease can significantly reduce the hospital stay.     

胆囊结石并发急性胰腺炎的超声诊断价值

目的探讨胆囊结石并发急性胰腺炎的超声诊断价值。方法采用超声检查37例胆囊结石并发急性胰腺炎患者,观察胆囊内结石大小与数量并进行比较,同时观察胰腺大小形态、实质回声及周围情况。结果胆囊结石中83.8%（31/37）为多发性结石,其中80.6%（25/31）为直径小于0.9cm的小结石。结论多发性且直径小的胆囊结石患者急性胰腺炎的发病率明显增高。超声检查胆囊结石可为临床提供急性胰腺炎的可能病因,并为胆囊结石患者选择性地施行胆囊切除术提供影像学诊断依据。     

胆囊癌合并胆囊结石的超声研究

目的 探讨易合并胆囊癌的高危胆囊结石声像图特征，为胆囊结石患者选择预防性胆囊切除提供影像学依据。方法 分析37例胆囊癌合并胆囊结石术前超声检查的声像图特点。结果 26例（71％）同时合并慢性胆囊炎。29例（78％）为单发结石且结石大小超过1cm。扫查时27例（73％）结石不移动。胆固醇性和混合性结石共33例（89％）。结论 单发、体积较大且移动性差的胆固醇性或混合性结石更倾向于合并胆囊癌，当超声检查发现上述特点，尤其是同时存在慢性胆囊炎时，提示有较强的预防性胆囊切除指征。     

Treatment of cholelithiasis in children with sickle cell disease

Medical and surgical advances have improved the treatment of cholelithiasis (ie, gallstones) in children with sickle cell disease (SCD). Children with SCD have an increased risk of developing pigment gallstones that initially may be asymptomatic but that can lead to acute symptoms of cholelithiasis. An elective laparoscopic cholecystectomy procedure is recommended for pediatric patients with SCD to prevent the risk of requiring an emergency cholecystectomy procedure. The primary benefits of this approach include a shorter hospital stay after surgery, decreased postoperative discomfort, decreased risk of complications, and a quicker return to normal activities. AORN J 77 (June 2003) 1170-1182.     

胆囊结石并发急性胰腺炎的超声诊断及价值

目的：探讨胆囊结石并发急性胰腺炎的超声诊断及价值。方法：采用超声检查32例胆囊结石并发急性胰腺炎患者,观察胆囊内结石大小与数量并进行比较,同时观察胰腺大小、形态、实质回声及周围情况。结果：胆囊结石中81.1%（26/32）为多发性结石,其中81%（21/26）为直径〈0.9cm的小结石。结论：多发性且直径小的的胆囊结石患者并发急性胰腺炎的发病率明显增高。超声检查胆囊结石可为临床提供急性胰腺炎的可能病因,并为胆囊结石患者选择性地施行胆囊切除术提供影像学诊断依据。     

Gallstones and biliary disease

Gallstones are common in the US and western countries. This article describes the pathogenesis of gallstone formation and the clinical manifestations and current approaches to diagnosis and treatment of the most common clinical conditions caused by gallstones: biliary colic, acute cholecystitis, choledocholithiasis, and acute gallstone pancreatitis. The role of widely used imaging techniques (transabdominal ultrasound, CT scan, MR imaging, and MRCP) and diagnostic and therapeutic endoscopy (endoscopic ultrasound, ERCP) is emphasized. This article is intended mainly for general practitioners, primary care physicians, and other specialists providing medical care to patients with gallstones and their complications.     

Severe complications of chronic cholelithiasis treatment

BackgroundGallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible.Case presentationWe present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management.ConclusionSpecial care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.     

Atypical gastrointestinal symptoms are not associated with gallstones in patients with spinal cord injury

OBJECTIVE: To determine if nonspecific gastrointestinal (GI) symptoms justify cholecystectomy in patients with spinal cord injury (SCI). DESIGN: The frequency of GI symptoms was determined in a sample of patients with SCI in whom the presence or absence of gallstones had been previously determined by screening ultrasonography or a known history of cholecystectomy. The prevalence of various symptoms in patients with and without gallstones was compared. SETTING: The Spinal Cord Injury Unit of the Veterans Affairs Puget Sound Health Care System, which provides rehabilitation and longitudinal primary care for SCI veterans. PATIENTS: Two hundred ninety-four patients who had undergone either right upper quadrant ultrasonography or cholecystectomy in the past, and who completed a questionnaire concerning GI symptoms. MAIN OUTCOME MEASURE: Bivariate logistic regression was used to calculate odds ratios (ORs) to determine the strength of associations between the presence of each symptom and the presence of gallstones. RESULTS: Pain in the right upper quadrant or epigastrium that occurred after meals or at night was significantly associated with gallstones (OR: 3.5; 95% confidence interval [CI] 1.02-11.73). Abdominal pain in other locations and nonspecific symptoms such as bloating and nausea, were not predictive of the presence of gallstones. CONCLUSIONS: Nonspecific symptoms in patients with SCI are not associated with gallstones and do not justify cholecystectomy in patients with otherwise asymptomatic gallstones.     

Recurrent Gallstone Ileus

Mechanical small bowel obstructions caused by gallstones account for 1% to 3% of cases. In these patients, 80% to 90% of residual gallstones in these patients will pass through a remaining fistula without consequence. Recurrent gallstone ileus has been reported in 5% of patients. We report the case of a woman, aged 72 years, who presented with mechanical small bowel obstruction caused by gallstone ileus. After successful surgical therapy for gallstone ileus, the patient''s symptoms recurred, and she was diagnosed with recurrent gallstone ileus requiring a repeat operation. While management of gallstone ileus can be achieved through a single-stage operation including enterolithotomy and cholecystectomy with repair of biliary-enteric fistula or by enterolithotomy alone, the literature supports enterolithotomy alone as the treatment of choice for gallstone ileus due to decreased mortality and morbidity. However, the latter approach does not obviate potential recurrence. We present this case of recurrent gallstone ileus to elucidate and review the pathogenesis, presentation, diagnosis, and consensus recommendations regarding management of this disorder.     

Genetics of gallstone disease

Background

Gallstone disease (GD) belongs to the most frequent disorders in gastroenterology and causes high costs in our health‐care systems. Gallstones are uncommon in children but frequent in adults, in particular in women, and are triggered by exogenous risk factors. Here, we summarize the current knowledge concerning the contribution of inherited predisposition to gallstone risk.

Design

In this review, we present the current data and recent research on the genetics of gallstone disease.

Results

Several GD‐predisposing gene variants have been reported, with most prominent effects being conferred by a common variant (p.D19H) of the hepatic and intestinal cholesterol transporter ABCG5/G8. A smaller group of patients might develop gallstones primarily due low phosphatidylcholine concentrations in bile as a result of loss‐of‐function mutations of the ABCB4 transporter (low phospholipid‐associated cholelithiasis syndrome). Regardless of the origin, the risk factors for gallstones lead to the supersaturation of bile with insoluble compounds, in particular cholesterol. As result, cholesterol stones develop and present the most frequent type of gallstones. Laparoscopic cholecystectomy with low morbidity and mortality is currently the most common and effective method for the therapy of symptomatic gallbladder stones.

Conclusions

Gallstone disease represents a multifactorial condition and previous studies have identified the major genetic contributors to gallstone formation. The increasing knowledge about the pathomechanisms of hepatobiliary metabolism and GD as well as the identification of additional risk factors might help to overcome the current invasive therapy by specific lifestyle intervention and precise molecular treatment.     

Cholelithiasis: diagnosis and current therapeutic options

More than 20 million people in the United States have gallstones and some 500,000 cholecystectomies are done annually. The cost to the American public is approximately 1.5 billion dollars per year. Biliary pain or "colic" is the classic presenting symptom in gallstone disease, occurring in 5 to 10 percent of symptomatic patients. Of significance is that 10 to 30 percent of symptomatic patients will present with atypical complaints, while 80 percent of people with gallstones are asymptomatic. It is crucial that a detailed history of clients' symptoms be ascertained to ensure an accurate diagnosis. New treatment modalities for cholelithiasis recently have been developed. These include oral bile salt therapy and gallstone lithotripsy. Knowledge of these options and their applications to symptomatic clients will enable health care providers to better formulate plans of education and intervention for clients with gallstone disease.     

Cholecystitis and cholelithiasis

Cholelithiasis and cholecystitis, with their complications, remain major health problems in the United States. At this time, cholecystectomy is the treatment of choice for all patients with symptomatic gallstones and those with acute cholecystitis, except those who are too ill to undergo surgery. Present therapeutic options may be summarized as follows: Asymptomatic patients and those with flatulence and dyspepsia who have gallstones should be observed. Those who have symptoms of biliary pain, gallstone-induced pancreatitis, or common duct stones should have corrective surgery. Those who refuse surgery or who aren't surgical candidates might be treated with dissolution therapy. Dissolution of gallstones with chemical agents and extracorporeal shock-wave lithotripsy show some promise. We need a better understanding of the etiology and formation of gallstones to address the disease from a preventive standpoint and reduce the incidence of cholelithiasis and cholecystitis, and their complications.     

Spontaneous biliary enteric fistulas

Biliary enteric fistulas usually occur as a complication of chronic cholelithiasis, may be difficult to document preoperatively, and often pose problems in surgical management. We reviewed 13 cases of spontaneous biliary enteric fistulas to identify methods of diagnosis, management, and complications. There was no specific set of clinical symptoms or signs that led to the diagnosis of a fistula. In six cases the diagnosis was made preoperatively by x-ray films showing pneumobilia, gallstone in the small bowel, or fistula. Initial surgical treatment included cholecystectomy in six cases, small bowel enterotomy and removal of gallstones in four, and vagotomy and antrectomy in one case. Two patients initially treated without operation were lost to follow-up. Eight complications occurred in six patients, and there were three deaths due to underlying cardiac disease. The morbidity and mortality of biliary enteric fistulas associated with chronic cholecystitis may be avoided by performing elective cholecystectomy when the patient is in optimal condition.     

Perihepatic,Pulmonary, and Renal Abscesses Due to Spilled Gallstones

Background

Spilled gallstones are common during laparoscopic cholecystectomy; however, they rarely lead to postoperative complications. Perihepatic abscesses develop in < 0.1% of patients with spilled gallstones and are typically contained within the peritoneal cavity.

Benign prostatic hyperplasia: when to 'watch and wait,' when and how to treat

Benign prostatic hyperplasia (BPH) is a clinical diagnosis. While BPH is a common cause of lower urinary tract symptoms (LUTS) in men, LUTS can signify a number of other disease states. For this reason, the patient evaluation, which includes a digital rectal examination, and careful differential diagnosis are crucial in men with LUTS. Many men with BPH are asymptomatic, and many others are not bothered by their symptoms; watchful waiting is appropriate management for these patients. When symptoms affect quality of life, pharmacologic therapy should be an option; choices include an alphablocker, a 5 alpha-reductase inhibitor, or, for men with larger prostates, a combination of the two. Surgical intervention is indicated when BPH leads to other medical complications, including urinary retention and renal insufficiency.     

Gallstones--surgical aspects

Between 10% to 15% of the adult population develop gallstones. Therefore, cholecystectomy is among the most common operations in general surgery. The diagnosis of cholelithiasis depends on the patient's history, clinical findings, laboratory tests and ultrasound examination. Once diagnosis of symptomatic gallbladder disease has been confirmed, laparoscopic cholecystectomy is the treatment of choice. Its advantages in comparison with open surgery are decreased morbidity, costs and hospital stay. Open cholecystectomy is still the treatment of choice for complicated gallstone disease (i.e. cancer, Mirizzi's syndrome, severe inflammation) and in high-risk patients. In case of acute cholecystitis, early laparoscopic cholecystectomy is a safe procedure and is associated with the same benefits as for symptomatic disease.     

Gallstone disease. Pathophysiology, epidemiology, natural history, and treatment options.

In 1991, only symptomatic gallstones should be treated. The treatment of choice for all gallstones continues to be surgical removal. Except for stones in the common bile duct, which are amenable to removal by endoscopic papillotomy, nonsurgical treatment of gallstones should be investigated further before it can have widespread applicability. The major challenge in the future may be medical prevention of gallstone formation in susceptible individuals. Laparoscopic cholecystectomy seems to have moved to the forefront of surgical therapy in patients who are candidates for the procedure.     

Calcium in human gallbladder bile.

Biliary calcium is believed to be of great importance in gallstone pathogenesis. These studies were therefore performed to determine if quantitative and/or qualitative differences in calcium are present in gallbladder bile from patients with and without gallstones. Bile was obtained by direct gallbladder aspiration from 68 obese patients undergoing elective gastric bypass surgery. Forty-five patients had no evidence of gallstones or sludge, 18 had cholesterol gallstones, and five had black pigment stones. Gallbladder bile was also obtained from 27 nonobese patients undergoing elective cholecystectomy (19 cholesterol; eight black pigment gallstones). For all patients, total calcium ranged from 1.50 to 16.44 mmol/L (mean: 6.05 +/- 0.31 mmol/L); free Ca++ ion ranged from 0.53 to 2.83 mmol/L (mean: 1.28 +/- 0.05 mmol/L). Considerable overlap was observed between obese and nonobese subjects and between patients with and without gallstones. For all patient groups, calcium, Ca++, and bound calcium increased linearly with increasing concentrations of bile salt. No significant differences in the slopes of these relationships were observed with obesity or gallstones. In contrast, free Ca++ ion was greater in gallbladder bile from gallstone patient groups throughout the entire range of bile salt. We hypothesize that this observed increase in Ca++ resulted from increased Gibbs-Donnan forces and excess gallbladder mucin present within the gallbladder bile of patients with gallstones.     

Intramural gallstones mimicking typical lithiasic cholecystitis

Gallstone disease is common in the western population. Intramural gallstones are rare, with only a few cases reported in the literature. We present a 30-year-old female patient with typical symptoms of cholecystitis. The patient underwent laparoscopic cholecystectomy one month later. Dark greenish intramural gallstones were identified right after the resection of the gallbladder, and the pathologic examination revealed adenomyomatosis of the gallbladder. To our knowledge, this is the first report of intramural gallstones presenting with cholecystitis. The presence of intramural gallstones is not easily detected during ultrasound examination, and does not affect the natural course or treatment of gallstone disease.