Cholelithiasis (Gallstones) – Causes, Diagnosis and Treatment

Cholelithiasis

Cholelithiasis, is a relatively common disease, over 10% of the adult population of European countries have this disease. In most cases, cholelithiasis is discovered during a routine abdominal ultrasound, but also can give symptoms.

Cholelithiasis

Causes:

The main causes incriminated in the development of cholelithiasis are:

• Genetic predisposition;
• Female gender: the ratio women / men being 2-3/1;
• Obesity;
• Age;
• Dyslipidaemia;
• Diabetes;
• Hypertriglyceridaemia.

Pathogenesis of cholelithiasis:

Cholelithiasis, occurs as a consequence of breaking the existing balance in the bile, where cholesterol, bile acids and lecithin are in a balance that ensures cholesterol solubilisation. An increase in the elimination of cholesterol (in dyslipidemia, the sudden loss weight, diabetes, obesity) or on the contrary, a decrease in bile acid secretion will lead to breaking the balance that ensures cholesterol solubilisation at its precipitation in the gallbladder, with cholesterol crystals development. Biliary stasis is another factor that favors the appearance of gallstones.

Diagnosis of cholelithiasis:

Clinical diagnosis of cholelithiasis can be put when appear a biliary colic or a dyspepsia that may suggest a biliary pain. It should be noted that  cholelithiasis is often asymptomatic or partially symptomatic and its diagnosis is made incidentally.

Paraclincal diagnosis of cholelithiasis is by abdominal ultrasound, which may reveal the presence of gallstones, as well as their number. Echo-endoscopy can be used as a diagnostic method in cases of cholelithiasis with uncertain ultrasound diagnosis.

Computer tomography (CT) can determine the calcium content of gallstones.

Classification of cholelithiasis:

A modern concept of cholelithiasis is the classification in:

1. Symptomatic cholelithiasis, it is the one that generates biliary colic.  Biliary colic represents a intense or violent pain in the epigastrium or right hypochondrium , lasting about 30 minutes. Nausea, vomiting and headache, occurring in outside of biliary colic, dose not represent symptomatic cholelithiasis.
2. Asymptomatic cholelithiasis is the form of the disease that does not cause biliary colic.

Cholelithiasis

Evolution:

Evolution of cholelithiasis is often unpredictable. In general, symptomatic cholelithiasis generates biliary colic, relatively frequent, which can be complicated by acute cholecystitis. Often asymptomatic cholelithiasis remain asymptomatic throughout life, but some clinical studies have shown that about 20% of asymptomatic cholelithiasis became symptomatic after 10 years of evolution.

Complications of cholelithiasis include:

• Biliary colic;
• Acute cholecystitis;
• Migration of gallbladder stones in coledoc;
• Vesicular hydrops;
• Acute pancreatitis;
• Gallbladder cancer.

The prognosis of cholelithiasis:

Cholelithiasis has often a good prognosis because symptomatic cases are most often solved by surgery and the asymptomatic forms are kept under surveillance.

Treatment of cholelithiasis:

Currently there is almost a consensus that asymptomatic cholelithiasis should be observed and not solved by surgery. Since only 1% -2% of the cases become symptomatic every year, observation of  asymptomatic cholelithiasis seems the most logical solution, remaining as if symptoms appear, to decide the therapy.

Symptomatic cholelithiasis  will be treated. Most often, the treatment will be surgical and rarely will be  performed by non-surgical techniques. With the introduction of laparoscopic cholecystectomy, was ensured a short period of hospitalization and minimal postoperative complications. This technique treats mostly uncomplicated cholelithiasis and acute cholecystitis or  vesicular hydrops.

Cholelithiasis

Non-surgical treatment techniques of cholelithiasis are drug litholysis and shock wave lithopripsy, less used lately due to the high degree of occurrence of the relapse.

Drug litholysis is addressed to cholesterol gallstones, preferably small. Treatment consists of administration of ursodeoxycholic acid or combined with chenodeoxycholic acid, for a period of 3 to 12 months, until the complete dissolution of gallstones apper. Chance of success is about 50% and the risk of relapse within 5 years is 10%. Supervision is done by abdominal ultrasound.

Shock Wave Lithotripsy, consists in bombing of cholesterol stones with shock waves. It is addressed to unique gallstones or less numerous stones, preferably less than 15 mm. Fragments will be dissolved by the administration of bile acids (ursodeoxycholic acid), up to complete disappearance of all fragments of stones from the gallbladder.