Cholelithiasis

Cholelithiasis is the most common biliary tract disease and one of the most common surgical indications. According to autopsy findings, up to 20–30% of the population is affected by cholelithiasis. It occurs four times more often in women, and it is more common in obese, diabetics and patients with prehepatic (hemolytic) jaundice. right|350px

Pathogenesis
Choledocholithiasis can be primary or more often secondary – a stone travels from the gallbladder to the bile duct. Stones are formed when there is a disproportion between the concentrations of the basic components of bile (cholesterol, bile acid salts and phospholipids).

Composition of stones: Division:
 * bilirubin, bile acids, calcium.
 * according to the predominant component,
 * cholesterol – - solitary, spherical, in cross section crystals of cholesterol are arranged the radiallyl . They are formed when there is an increased concentration of cholesterol in the bile (cause – high fat diet;),
 * pigment:
 * black – solid, multiple, they occur in the gallbladder during hemolytic  jaundice  (increased bilirubin);
 * brown – oily, usually in the bile ducts during cholestasis and inflammation;
 * mixed  (most common in the Czech Republic) - multiple, faceted stones, they occur mainly in the chronically inflamed gallbladder, their presence is considered precancerous;
 * according to the shape –so-called sand ("gallbladder sludge"), larger solitary or multiple stones (multiple stones have a polyhedral shape with flat areas - facets - in places of mutual contact → faceted stones).

Etiology

 * High fat diet – cholesterol stones;
 * hemolysis  – black pigment stones;
 * cholestasis  – brown pigment stones in the choledochus;
 * inflammation – brown pigment stones in the choledochus, mixed stones in the gallbladder;
 * stones can be both a cause and a consequence of inflammation and cholestasis;
 * cystic obstruction causes billiary  colic and can lead to acute cholecystitis;
 * risk factors include high fat diet, obesity, hemolytic states, pregnancy, DM.

Clinical picture

 * Asymptomatic form


 * Dyspeptic form:
 * non-specific symptoms - pressure in the abdomen, nausea, vomiting, belching, flatulence, feeling of tension after eating food with fats;;
 * sensitivity in the right lower area under rib cage, positive Murphy's sign.


 * Colica form:
 * typical manifestation of the disease;
 * when there is closure of the cystic duct with a stone;
 * provocative moment - dietary mistake - foods rich in fats, eggs, chocolate, mental shocks, anger;
 * but often just drinking water is enough;
 * night attacks - they are explained by easier clogging of the cystic duct in a horizontal position;
 * they can happen often, almost daily, or in other cases they do not recur for years.


 * Nature of pain:
 * sudden onset of severe convulsive pain in the area under right rib cage, radiates under the right shoulder blade;
 * in contrast to inflammation - this pain forces the patient to move and look for a relief position;
 * The pain may spread to the precordium and mimic ischemic coronary heart disease;

Diagnosis
thumb|ERCP – kámen ve žlučovodu
 * Simple billiary colic lasts for several hours.
 * Prolonged pain - beginning of inflammation of the gallbladder is suspected
 * Usually a typical clinical picture, to confirm - USG, X-ray of the abdomen (stones, if they contain Ca2+).
 * Oral cholecystography, or cholangiography - recommended only after the pain has subsided (for example, after 2-3 weeks).
 * The ERCP (Endoscopic retrograde cholangiopancreatography ) gives us an accurate idea of the shape and placement.

Complication
When fused with the surroundings, the stones can travel as biliodigestive fistula into the surrounding structures - duodenum, colon transversum, choledochus, abdominal wall - biliary ileus;
 * Acute and chronic cholecystitis - we always find different degrees of inflammation, it is difficult to decide what was the first;
 * Gallbladder Hydrops - Clogging of the cystic duct, a palpable pear-shaped formation underneath rib cage ;
 * Choledocholithiasis - smaller stones pass through the cyst, they can get blocked in the papilla - pancreatitis, obstructive jaundice, cholangitis; …
 * Gallbladder cancer;

Differential diagnostics

 * Ulcer, pancreatitis, hepatitis, gallbladder carcinoma, distension of the hepatic flexion of the colon, irritable bowel syndrome, subhepatic appendicitis, kidney, AIM (acute infarct of myocard) and others.

Therapy
thumb|Duodenoskopie – extrakce pigmentového kamenu ze žlučovodu
 * We treat colic without infection by resting in bed, local application of warm compresses (if we are sure that it is not inflammation);
 * We administer analgesics and antispasmodics (Spasmoveralgin, Dolsin;…).
 * The first two days, until calming - a tea diet;
 * After subside of the attack - gallbladder diet;
 * There is no conservative treatment for lithiasis (other than cholesterol);
 * administration of chenodeoxycholic acid - dissolution of cholesterol stones, frequent recurrences;
 * Lithotripsy - compared to the previous treatments it has little results;
 * Radical method of treatment - cholecystectomy - classically or laparoscopically;
 * should be performed as soon as possible after evidence of cholelithiasis - this will reduce the percentage of complications;

Related articles

 * Diseases of the gallbladder and pancreas in children
 * Lithiasis
 * Cholecystectomy
 * Choledocholithiasis