Желчнокаменная болезнь

Definition - the formation of gallstones

Pathogenesis

• imbalance of cholesterol and its solubilizing agents (bile salts and lecithin)

• excessive hepatic cholesterol secretion → bile salts and lecithin are "overloaded" →

• supersaturated cholesterol can precipitate and form gallstones

Risk Factors

• cholesterol stones:

  • obesity, age <50

  • estrogens: female, multiparity, OCPs

  • ethnicity: First Nations heritage (especially Pima Indians) > Caucasian > Black

  • terminal ileal resection or disease (e.g. Crohn's disease)

  • impaired gallbladder emptying: starvation, TPN, DM

  • rapid weight loss: rapid cholesterol mobilization and biliary stasis

• pigment stones (contain calcium bilirubinate):

  • cirrhosis

  • chronic hemolysis

  • biliary stasis (strictures, dilation, biliary infection)

• protective factors: statins, vitamin C, coffee

Клиника

asymptomatic (80%):

• • most do NOT require treatment

  • consider cholecystectomy if: increased risk of malignancy (choledochal cysts, Caroli's disease, porcelain or calciffed gallbladder), sickle cell disease, pediatric patient, bariatric surgery, diabetes, immunosuppression

  • biliary colic (10-25%)

• Cholecystitis

  • choledocholithiasis (8-15%)

• Cholangitis

  • gallstone pancreatitis

  • gallstone ileus

Investigations

• U/S – diagnostic procedure of choice:

  • image for signs of in ammation, obstruction, localization of stones

• ERCP (endoscopic retrograde cholangiopancreatography):

  • visualization of upper GI tract, ampullary region, biliary and pancreatic ducts

  • method for treatment of CBD stones in periampullary region

  • complications: traumatic pancreatitis (1-2%), pancreatic or biliary sepsis

• MRCP (magnetic resonance cholangiopancreatography):

  • same information gained as ERCP but non-invasive

  • cannot be used for therapeutic purposes

• PTC (percutaneous transhepatic cholangiography):

  • injection of contrast via needle passed through hepatic parenchyma

  • useful for proximal bile duct lesions or when ERCP fails or not available

  • requires prophylactic antibiotics

  • contraindications: coagulopathy, ascites, peri/intrahepatic sepsis, disease of right lower lung or pleura

  • complications: bile peritonitis, chylothorax, pneumothorax, sepsis, hemobilia

• HIDA scan (hepatobiliary imino-diacetic acid scan):

  • used less commonly

  • radioisotope technetium-99 injected into a vein is excreted in high concentrations into bile, allowing visualization of the biliary tree

  • does not visualize stones; diagnosis by seeing occluded cystic duct or CBD