INCIDENCE, ASYMPTOMATIC GALLSTONE, DIAGNOSIS AND COMMON SYMPTOMS OF GALLSTONES

Incidence -

Age

Incidence increases with age

• Cholesterol and cholesterol saturation index is high in elderly women
• Sensitivity to CCK decrease with age
  • Pancreatic polypeptide increases with age

Gall stones in children

• Haemolytic diseases
• Congenital disorders
• Short bowel syndrome
• Pt. On TPN

GALLBLADDER DISEASE PREVALENCE BY AGE GROUP
Percentage With Stones
Age (y) Female Male
10-39 5.0 1.5
40-49 12.0 4.4
50-59 15.8 6.2
60-69 25.4 9.9
70-79 28.9 15.2
80-89 30.9 17.9
90+ 35.4 24.4

Diet

• Diet plays an important role in cholesterol supersaturation.
• Cholesterol gallstones are common in populations consuming a Western diet, which is relatively high in animal fat.
• The incidence of cholesterol gallstones rises in a population as it shifts to a higher consumption of dietary fat.

Gender and harmone

Females have much high incidence of gall stones

• Estrogen decreases activity of the hepatic enzyme (7-a-hydroxylase)responsible for converting cholesterol to bile acids,
• Pregnancy
  • progesterone decreases gall bladder contractility
  • relative overproduction of hydrophobic bile acids such as chenodeoxycholate
• Oral contraceptives and estrogen replacement therapy

Family history and genetics

• Gallstones occurred more than twice as often in the family group
• A dramatic example occurs in Pima Indians
• 73 percent in women over the age of 25 years

Obesity,diabetes, vagotomy

• Obesity causes secretion of bile with high concentration of cholesterol
• Rapid weight loss in morbid obese,- low calorie diet- increased fat metabolism
• Bile mucin content increased 18-fold and bile calcium concentration rose 40 percent.

Diabetes mellitus- two fold increase in incidence
• High cholesterol, low bile acid
• Biliary stasis-autonomic neuropathy

Cirrhosis

• Cirrhosis – pigment stones
  • Hypersplenism,
  • reduced hepatic synthesis and transport of bile salts
  • Increase in nonconjugated bilirubin,
  • High estrogen levels, and
  • Impaired gallbladder contraction in response to a meal.

Gallblader stasis
• Somatostatin, otreotide.
• TPN – no stimulation to gallbladder.
Drugs

• Clofibrate – cholesterol lowering agent -reduce bile acid secretion by inhibiting enzyme cholesterol 7-alpha-hydroxylase;
• Estrogen, oral contraceptives
• Ceftriaxone-
• Biliary excretion accounts for up to 40 percent of ceftriaxone elimination.
• Concentrations in bile can reach 200 times that of the serum.
• When supersaturated, ceftriaxone complexes with calcium and precipitates out of bile.

Asymptomatic gallstones

• 50% of all gall stones are asymptomatic.
• 20% to 30% of patients become symptomatic within 20 years.
• 1% to 2% of asymptomatic individuals with gallstones per year develop serious symptoms or complications related to their gallstones.
• Many of them have some kind symptoms including dyspepsia.
• All patients will develop symptomatic disease before developing one of the complications of gallstones.
• Prophylactic cholecystectomy is debatable.

Indications of Prophylactic cholecystectomy

• Choledochal cysts.
• Caroli's disease.
• Long common channel of bile and pancreatic ducts.
• Pediatric gallstones.
• Congenital hemolytic anemia.
• Gallstones >2.5 cm in diameter.
• Calcified (porcelain) gallbladder.
• Incidental gallstones found during intraabdominal surgery.
• No access to medical care.
• Gallbladder adenomas .
• Porcelain gallbladder.
• Gastric bypass surgery in morbid obesity.

Diagnosis of gall stones


X-ray abdomen AP

• Up to 20% gall stones are radio-opaque.
• Air may be trapped in cholesterol stone.
• Air in the wall or in the lumen of gall bladder – emphysematous cholecystitis.
• Air in the biliary tree – entero-biliary fistula.
• Outlining of gallbladder – porcelain gallbladder or milk of calcium bile.

Oral cholecystography (OCG)

• Based on excretion of halogenated compound by liver and concentration by gallbladder.
• Traditionally it has been a gold standard diagnostic test with 95% specificty.
• Inability to absorb the tablet gives no result.
• Can’t be used in hepatic dysfunction and obstruction.

Abdominal ultrasonography

Most preferred investigation
• Non-invasive, no radiation.
• Gives idea of intrahepatic and extrahepatic biliary channels too.
• Gives idea of pancreas and other abdominal organs.
• Tells about inflammation of the organ.
• Patients should receive nothing by mouth for several hours prior to performing an ultrasound examination so that the gallbladder is fully distended.
• Gallstones create echoes that are reflected back to the ultrasound probe.
• The ultrasound waves cannot penetrate the stones; and therefore, acoustic shadowing is seen posterior to the stones .
• In addition, gallstones that are free-floating in the gallbladder will move to a dependent position when the patient is repositioned during scanning.
• When these two features are present, the accuracy is 100%.
• Echoes without shadows may be caused by gallbladder polyps.

Drawback of USG

• Small gallstones may not demonstrate an acoustic shadow.
• Furthermore, a lack of fluid (bile) around the gallstones (stone impacted in cystic duct, gallbladder filled with gallstones) also impairs their detection.
• In addition, an ileus with increased abdominal gas as occurs with acute cholecystitis may hamper gallbladder visualization.
• Overall, the false negative rate for ultrasound in detecting gallstones is approximately 5% but may increase to 15% with acute cholecystitis.

Hepatobiliary scintigraphy

• 99mTechnetium labeled iminodiacetic acid derivatives (hepatic 2,6-dimethyl-iminodiacetic acid [HIDA], diisopropyl-acetanilido-iminodiacetic acid, P-isopropylacetanilido imidodiacetic acid) are injected intravenously, rapidly extracted from the blood, and excreted into the bile.
• Uptake by the liver, gallbladder, CBD, and duodenum should all be present after 1 hour.
• Slow uptake of the tracer by the liver suggests hepatic parenchymal disease.
• Filling of the gallbladder and CBD with delayed or absent filling of the intestine suggests an obstruction at the ampulla.
• Nonvisualization of the gallbladder 1 hour after the injection of the radioisotope with filling of the CBD and duodenum is consistent with total or partial cystic duct obstruction and acute cholecystitis.

Computerized Tomography/Magnetic Resonance Imaging

• Abdominal computed tomography (CT) is less sensitive in diagnosing gallstones than ultrasound.
• Calcified gallstones are visualized in approximately 50% of patients.
• The role of CT scanning is primarily limited to the diagnosis of complications of gallstone disease such as acute cholecystitis (gallbladder wall thickening, pericholecystic fluid), choledocholithiasis (intrahepatic and extrahepatic bile duct dilation), pancreatitis (pancreatic edema and inflammation), and gallbladder cancer.
• More recently, magnetic resonance imaging (MRI)has been shown to be highly sensitive in the diagnosis of both gallstones and common duct stones when heavily weighted T2-weighted images are obtained .

Common clinical features
Non specific symptoms-

• upper right abdominal discomfort.
• Vague, poorly localised pain mainly in right hypochondrium and or in epigastrium usually follows meals.
• Flatulence, eructation and heartburn.

Biliary colic

• Usually associated with impacted stone in Hartmann pouch or in cystic duct or passage of stone through these structures.
• It is not exactly a colic as it is not for short bouts of pain with total remission in between
• Biliary colic is characterized by a rapid increase in pain intensity, with a plateau of discomfort that lasts for several hours, followed by a gradual decrease in intensity.
• Situated in right upper quadrant or middle epigastrium.
• Radiates to inferior angle of right scapula and referred to right shoulder.