Kembara Xtra - Medicine - Cholelithiasis

Kembara Xtra - Medicine - Cholelithiasis
Introduction Gallstones are referred to as the presence of cholesterol, pigment, or mixed stones (calculi) within the gallbladder.
Pediatric Considerations Rare in children under 10 years Pigment stones linked to blood dyscrasias make up the majority of gallstones in children.

Incidence and prevalence in epidemiology 

Gallstones are more common in Native Americans and Hispanics, and their incidence rises with age, increasing by 3% to 7% annually, peaking in the seventh decade. In the United States, 2% of the population gets gallstones every year.
Prevalence
Gallstones affect 8–10% of Americans, 20% of whom are over 65, and women outnumber men by a ratio of 2:1 to 3:1.

Pathophysiology and Etiology 
Gallstone production is a complicated process that is influenced by environmental, immunological, metabolic, and genetic variables.
The nidus for gallstone production is gallbladder sludge, which is composed of calcium bilirubinate granules, cholesterol crystals, and mucus gel matrix.
Cholesterol-supersaturated bile (cholesterol stones) forms as agglomerated, expanding microcrystals.
Biliary stasis or decreased gallbladder motility both promote stone development.
A reduction in the release of bile salts or bile phospholipids (lecithin).
Excess unconjugated bilirubin in people with hemolytic illnesses; transit of excessive bile salt into the colon followed by absorption of excessive unconjugated bilirubin in people with inflammatory bowel disease (IBD) or after distal ileal resection (black or pigment stones)
In individuals with biliary system infections or strictures (brown stones or primary bile duct stones; uncommon in the West but frequent in Asia), bacteria can hydrolyze conjugated bilirubin or phospholipid.

Risk Elements

Patients peak between the ages of 60 and 80. Female gender, pregnancy, multiparity, obesity, and metabolic syndrome
Native American, Hispanic, or Caucasian ancestry
A high-fat, high-cholesterol diet
Long-term total parenteral nutrition (TPN), after vagotomy, long-term somatostatin medication, and rapid weight loss are all associated with cholestasis or reduced gallbladder motility.
Hemolytic illnesses (hereditary spherocytosis, sickle cell anemia, etc.), cirrhosis (black/pigment stones), short gut syndrome, terminal ileal resection, and IBD are hereditary (p.D19H variation for the hepatic canalicular cholesterol transporter ABCG5/ABG8).
Medicines (birth control pills, high-dose estrogen replacement treatment, and long-term corticosteroid or cytostatic medication); viral hepatitis, biliary tract infection, and stricture (which encourages intraductal pigment stone formation); biliary tract infection; and pigment stone formation.


Prevention
Gallstone development may be decreased by regular exercise and dietary changes.
By lowering bile cholesterol saturation, lipid-lowering medications (statins) may prevent cholesterol stone development.
When used during rapid weight reduction, ursodiol (Actigall) helps to reduce gallstone formation.

Accompanying Conditions 

Gallstones and chronic cholecystitis are present in 90% of patients with gallbladder cancer.

The majority of patients (80%) are asymptomatic; just 2% of people experience symptoms annually. About 50% of persons with gallstones experience symptoms at some point in their lives.
Episodic pain in the right upper quadrant or epigastrium that lasts more than 15 minutes and occasionally radiates to the back (biliary colic caused by a temporary cystic duct obstruction) Pain is typically postprandial, especially after a fatty meal, but it can occasionally rouse patients from sleep.
After a first episode of biliary colic, the majority of patients experience recurrent symptoms.
● Other signs and symptoms include an aversion to fatty foods, nausea, vomiting, and indigestion or bloating.
Gallstone illness may first show symptoms in the form of complications (such as gallstone pancreatitis).


clinical assessment 
In the absence of an acute attack, a physical examination in cholelithiasis patients is typically unremarkable.
Tenderness in the right upper quadrant and/or the epigastrium (the Murphy sign) is a classic physical indication of acute cholecystitis. Murphy sign's sensitivity and specificity are constrained.
Reynolds pentad: fever, jaundice, right upper quadrant pain, hemodynamic instability, and changes in mental status; also traditionally associated with ascending cholangitis. Charcot triad: flank and periumbilical ecchymoses (Cullen sign and Grey Turner sign) in patients with acute hemorrhagic pancreatitis. Courvoisier sign: palpable mass in the right upper quadrant in patient with obstructive cholangio

Differential Diagnosis Gallbladder cancer, gallbladder polyps, Acalculous Cholecystitis, Biliary Dyskinesia, Choledocholithiasis, Gastritis, Peptic Ulcer Diseases, Pancreatitis, Cholangitis, Cholangitis


Diagnostic tests and laboratory results 
The preferred diagnostic method for cholelithiasis is ultrasound.
Initial examinations (lab, imaging)
In acute calculus cholecystitis, leukocytosis and an increased C-reactive protein level are frequent.
The imaging modality of preference is ultrasound (US). Gallstones are found by US in 97-98% of patients.
Acute cholecystitis is indicated by a thickening of the gallbladder wall (5 mm), pericholecystic fluid, and direct soreness when the probe is pressed on the gallbladder (sonographic Murphy sign).
The only benefit of CT scan over US is its ability to identify distal common bile duct (CBD) stones.
MR cholangiopancreatography (MRCP) is only used in situations where CBD stones may be present. However, in the diagnosis of patients with suspected CBD stones and patients with mild to moderate gallstone pancreatitis (GP), MRCP is not more cost-effective than early cholecystectomy with cholangiography and has no therapeutic efficacy.
For the identification of CBD stones in individuals with GP, endoscopic US is just as sensitive as endoscopic retrograde cholangiopancreatography (ERCP).
The diagnosis of acute cholecystitis caused by cystic duct obstruction can be made with a hepatobiliary iminodiacetic acid (HIDA) scan. In separating acalculous cholecystitis from other causes of stomach pain, it is also helpful. Fasting, poor sphincter of Oddi resistance, and gallbladder agenesis can all cause false-positive findings.

Gallbladder dysmotility (biliary dyskinesia) is specifically diagnosed with cholecystokinin (CCK)-HIDA.
A conventional x-ray can show radiopaque calcium or pigment-containing gallstones, which make up 10–30% of all gallstones. A "porcelain gallbladder" is a calcified gallbladder that is linked to chronic cholecystitis and gallbladder cancer and can be seen on an x-ray.

Interpretation of Tests
Pigment stones might be black or brown, while pure cholesterol stones are typically white or slightly yellow. Black stones almost often occur in the gallbladder and include polymerized calcium bilirubinate, most frequently as a result of cirrhosis or hemolysis.
Brown stones typically form in the bile ducts because they are related with biliary system infection, which is brought on by bile stasis.

Treatment 
Treat symptomatic cholelithiasis; conservative treatment is favored during pregnancy; if surgery is required, it should be performed in the second trimester.
Prophylactic cholecystectomy for those at risk for gallbladder cancer due to calcified (porcelain) gallbladders, those with large stones (those over 3 cm), those with sickle cell disease, those with pediatric gallstones, those preparing for organ transplants, and those with recurrent pancreatitis brought on by microlithiasis.
Cholecystectomy may be carried out with bariatric treatments in patients who are excessively obese in order to lessen comorbidities caused by later stone-related conditions.
When gallstones are unintentionally found during open abdominal surgery, prophylactic cholecystectomy is advised.
Aspects of Geriatrics
The elderly are more likely to develop gallstones. Age alone shouldn't change the treatment strategy.

The First Line of Medicine
NSAIDs, which are analgesics that are equal to opioid therapy, are the first-choice medication for pain control. Patients who are unable to take NSAIDs or who do not respond to them may be prescribed opioids.
Prophylactic antibiotics in low-risk individuals do not shield against infections during laparoscopic cholecystectomy (LC) in patients with acute cholecystitis.
QUESTIONS FOR REFERENCE
After cholecystectomy, patients with residual or recurrent bile duct stones should be referred for ERCP.

Surgical Techniques
people with symptomatic cholelithiasis or problems from gallstones (such as cholecystitis), as well as asymptomatic people with immune suppression, calcified gallbladders, huge gallstones (more than 3 cm), or a family history of gallbladder malignancy, should be given surgical options.
The mortality and complication rates for open and LC are comparable. LC is the current gold-standard treatment since it provides less pain and a quicker recovery.
Robotic cholecystectomy (RC) is an option to laparoscopic cholecystectomy (LC) in carefully chosen patients. In terms of pain and complication risk, RC has not been proven to be superior to LC and is connected with higher costs. CBD injury (0.4-0.6%), right hepatic duct/artery injury, retained stones, bile leak, biloma development, and bile duct stricture are among the complications of surgery. It has been demonstrated that bile spilling during LC increases the risk of surgical site infection.
Clinical judgment is used to decide whether to convert to open procedure. This is not a surgical complication; rather, it is a choice to do the procedure in the safest possible way. Acute cholecystitis, thickening gallbladder wall, male gender, prior upper abdominal surgery, and male gender all enhance the likelihood that an open procedure may be necessary.
- Intraoperative cholangiograms (IOC) reveal CBD stones in 10-15% of patients with symptomatic cholelithiasis. By either postoperative ERCP or laparoscopic CBD investigation, CBD stones can be removed. When dissection is challenging, IOC aids with the bile duct anatomical definition. It is debatable whether routine IOC use is linked to a reduction in the frequency and seriousness of bile duct damage.
Early LC (24 hours following biliary colic diagnosis) reduces hospital stay and surgical time.
Early LC (7 days of clinical presentation) is safe and may minimize the overall hospital stay for patients with acute cholecystitis compared to delayed LC (>6 weeks after first admission with acute cholecystitis).

In challenging surgical situations (such severe cholecystitis), partial or total cholecystectomy and laparoscopic fundus-first cholecystectomy are possible choices.
For high-risk cholecystitis or gallbladder empyema patients, percutaneous cholecystostomy (PC) is used.
A periodic cholecystectomy is advised.
Oral disintegration therapy (ursodiol [Actigall]) is an option for symptomatic patients who are not candidates for surgery or those who have small gallstones (5 mm or smaller) in a healthy gallbladder with a patent cystic duct. Once the medicine is stopped, the recurrence rate is greater than 50%.
When a patient cannot undergo surgery, cystic duct stenting via ERCP is a potential alternative for treating severe acute cholecystitis, gallbladder hydrops, or empyema. To transition to laparoscopic cholecystectomy, it can be employed.
For symptomatic patients who are not candidates for surgery, extracorporeal shock wave lithotripsy offers a noninvasive therapeutic alternative. Before ERCP, it assists in dissolving large bile duct stones. Biliary pancreatitis, hepatic hematomas, inadequate ductal stone clearance, and recurrence are examples of complications.


Admissions

LC is frequently performed on symptomatic cholelithiasis patients as an outpatient procedure. Inpatient treatment is required for individuals who have complications, such as cholecystitis, cholangitis, or pancreatitis.
NPO, IV fluids, and antibiotics during the acute phase
Effective pain management using opioids and/or NSAIDs

Patient Follow-Up Monitoring
Follow patients taking oral dissolving medications with serial liver enzymes, serum cholesterol, and imaging to look for symptoms of symptomatic cholelithiasis.

Diet
A low-fat diet might be helpful.

Hospitalizations because of gallstones may be decreased by lifestyle modifications (such as regular exercise) and dietary changes (such as a low-fat diet and a reduction in total calorie intake).
It is important to inform patients with asymptomatic gallstones about the typical signs of biliary colic and any potential side effects.

50% of people with gallstones have symptoms, according to the prognosis.
In elective instances, cholecystectomy-related mortality is 0.5%; in emergency cases, it is 3-5%; in elective cases, it is 10%; and in emergency cases, it is 30–40%.
After cholecystectomy, stones may return in the biliary tree in individuals with related risk factors because 10–15% of people have choledocholithiasis.

Complications
Acute cholecystitis (caused by gallstones in 90–95%)
In individuals with mild GP, ERCP sphincterotomy is not clearly beneficial, although it lessens problems in patients with severe GP.

CBD stones accompanied by acute cholangitis and obstructive jaundice. Early LC lowers the likelihood of subsequent biliary events in individuals following ERCP for CBD stones.
Gallstones with biliary-enteric fistula ileus
The condition known as Bouveret syndrome is a form of gallstone ileus in which a gallstone lodges in the duodenum or pylorus and blocks the gastric outflow.
Gallbladder cancer and Mirizzi syndrome, an obstruction of the external bile duct brought on by gallstones stuck in the cystic duct or gallbladder,

---