An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.
Cholecystitis; Choledocholithiasis; Bile duct stones
Gallstones are small, hard deposits that can form in the gallbladder, a sac-like organ that lies under the liver on the right side of the abdomen. Most people with gallstones don't even know they have them. But in some cases a stone may cause the gallbladder to become inflamed, resulting in pain, infection, or other serious complications.
The formation of gallstones is a complex process that starts with bile, a fluid composed mostly of water, bile salts, lecithin (a fat known as a phospholipid), and cholesterol. Most gallstones are formed from cholesterol.
The process of gallstone formation is referred to as cholelithiasis. It is generally a slow process, and usually causes no pain or other symptoms. The majority of gallstones are either the cholesterol or mixed type. Gallstones can range in size from a few millimeters to several centimeters in diameter.
Most gallstones are formed from cholesterol. Pigment stones are also very common; they are formed from a brown-colored substance called calcium bilirubinate. Patients can have a mixture of the two gallstone types.
Cholesterol Stones. Although cholesterol makes up only 5% of bile, about three-fourths of the gallstones found in the US population are formed from cholesterol. Cholesterol gallstones typically form in the following way:
Supersaturation and cholelithiasis can occur as a result of various abnormalities, although the cause is not entirely clear. There are many events that may promote cholelithiasis:
Pigment Stones. Pigment stones are composed of calcium bilirubinate, or calcified bilirubin. Pigment stones can be black or brown.
Mixed stones. Mixed stones are a mixture of cholesterol and pigment stones.
Gallstones can also be present in the common bile duct, rather than the gallbladder. This condition is called choledocholithiasis.
Secondary Common Bile Duct Stones. In most cases, common bile duct stones originally form in the gallbladder and pass into the common duct. They are then called secondary stones. Secondary choledocholithiasis occurs in about 10% of patients with gallstones.
Primary Common Bile Duct Stones. Less often, the stones form in the common duct itself (called primary stones). Primary common duct stones are usually of the brown pigment type and are more likely to cause infection than secondary common duct stones.
Gallbladder disease can occur without stones, a condition called acalculous gallbladder disease. This refers to a condition in which a person has symptoms of gallbladder stones, yet there is no evidence of stones in the gallbladder or biliary tract. It can be acute (arising suddenly) or chronic (persistent).
Afdhal NH. Diseases of the Gallbladder and Bile Ducts. In: Goldman L, Ausiello D. (eds.). Cecil Textbook of Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007.
Chambrlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg. 2009 May 2 [Epub ahead of print].
Chari RS, Shah SA. Biliary system. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 18th ed. St. Louis, MO: WB Saunders;2007:chap 54.
Dray X, Joy F, Reijasse D, et al. Incidence, risk factors, and complications of cholelithiasis in patients with home parenteral nutrition. J Am Coll Surg. 2007;204(1):13-21.
Gurusamy, KS, Samraj K. Cholecystectomy versus no cholecystectomy in patients with silent gallstones. Cochrane Database Syst Rev. 2007;(1):CD006230.
Ito K, Ito H, Whang EE. Timing of Cholecystectomy for Biliary Pancreatitis: Do the Data Support Current Guidelines? J Gastrointest Surg. 2008 Jul 18 [Epub ahead of print].
Konstantinidis IT, Deshpande V, Genevay M, Berger D, Fernandez-del Castillo C, Tanabe KK, et al. Trends in presentation and survival for gallbladder cancer during a period of more than four decades. Arch Surg. 2009;144(5):441-447.
Liu B, Beral V, Balkwill A, Green J, Sweetland S, Reeves G, et al. Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women. BMJ. 2008;337:a386. Doi: 10.1136/bmj.a386.
Portenier DD, Grant JP, Blackwood HS, et al. Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007; 3(4):476-479.
Rosing DK, de Virgilio C, Yaghoubian A, et al. Early cholecystectomy for mild to moderate gallstone pancreatitis shortens hospital stay. J Am Coll Surg. 2007;205(6):762-766.
Strasberg SM. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804-2811.
Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc. 2008;67(2):235-244.
Verbesey JE, Birkett DH. Common bile duct exploration for choledocholithiasis. Surg Clin N Am. 2008;88(6):1315-1328.
Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7):1004-1021.
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