Cholelithiasis - Causes, Symptoms And Treatment

Diseases of the gallbladder and biliary tract are common and, in many cases, painful conditions that may be life threatening and usually require surgery. They are generally associated with deposition of calculi and inflammation.

Cholelithiasis is the fifth leading cause of hospitalization among adults and accounts for 90% of all gallbladder and duct diseases. Women have two to three times the incidence as men of developing cholelithiasis. The disease may also be more prevalent in persons who are obese, who have high cholesterol, or who are on cholesterol lowering drugs. The prognosis is usually good with treatment unless infection occurs, in which case prognosis depends on its severity and response to antibiotics.

In most cases, gallbladder and bile duct diseases occur during middle age. Between ages 20 and 50, they're six times more common in women, but incidence in men and women becomes equal after age 50. Incidence rises with each succeeding decade.

Causes of Cholelithiasis

Cholelithiasis stones or calculi (gallstones) in the gallbladder. results from changes in bile components. Gallstones are made of cholesterol, caldurn bilirubinate, or a mixture of cholesterol and bilirubin pigment. They arise during periods of sluggishness in the gallbladder due to pregnancy. hormonal contraceptives. diabetes mellitus. celiac disease, cirrhosis of the liver, and pancreatitis.

One out of every 10 patients with gallstones develops Cholelithiasis, or gallstones in the common bile duct (sometimes called common duct stones). This condition occurs when stones pass out of the gallbladder and lodge in the hepatic and common bile ducts. obstructing the flow of bile into the duodenum. Prognosis is good unless infection occurs.

Cholangitis, infection of the bile duct, is commonly associated with choledocholithiasis and may follow percutaneous transhepatic cholangiography or occlusion of endoscopicstents. Predisposing factors may include bacterial or metabolic alteration of bile acids. Widespread inflammation may cause fibrosis and stenosis of the common bile duct. The prognosis for this rare condition is poor without stenting or surgery.

Cholecystitis. acute or chronic inflammation of the gallbladder. is usually associated with a gallstone impacted in the cystic duct, causing painful distention of the gallbladder. Cholecystitis accounts for 10% to 25% of all patients requiring gallbladder surgery. The acute form is most common during middle age; the chronic form occurs most commonly among the elderly. The prognosis is good with treatment.

Cholesterolosis. polyps or crystal deposits of cholesterol in the gallbladder's submucosa, may result from bile secretions containing high concentrations of cholesterol and insufficient bile salts. The polyps may be localized or speckle the entire gallbladder. Cholesterolosis the most common pseudotumor. isn't related to widespread inflammation of the mucosa or lining of the gallbladder. The prognosis is good with surgery.

Biliary cirrhosis. ascending infection of the biliary system, sometimes follows viral destruction of liver and duct cells. but the primary cause is unknown. This condition usually leads to obstructive jaundice and involves the portal and periportal spaces of the liver. It's nine times more common among women ages 40 to 60 than among men. The prognosis is poor without liver transplantation.

Gallstone ileus results from a gallstone lodging at the terminal ileum; it's more common in the elderly. The prognosis is good with surgery.

Postcholecystectomy syndrome commonly results from residual gal1stones or stricture of the common bile duct. It occurs in 1 % to 5 % of all patients whose gallbladders have been surgical1y removed and may produce right upper quadrant abdominal pain, biliary colic, fatty food intolerance, dyspepsia. and indigestion. The prognosis is good with selected radiologic
procedures, endoscopic procedures, or surgery.

Acalculous cholecystitis is more common in critical1y ill patients, accounting for about 5% of cholecystitis cases. It may result from primary infection with such organisms as Salmollella typhi. Escherichia coli, or Clostridium or from obstruction of the cystic duct due to lymphadenopathy or a tumor. It appears that ischemia usually related to a low cardiac output. also has a role in the pathophysiology of this disease. Signs and symptoms of acalculous cholecystitis include unexplained sepsis, right upper quadrant pain, fever, leukocytosis, and a palpable gallbladder.

Cholelithiasis Symptoms and Signs

Although gallbladder disease may produceno symptoms. acute cholelithiasis, acute cholecystitis, choledocholithiasis. and cholesterolosis produce the symptoms of a classic gallbladder attack. Attacks commonly follow meals rich in fats or may occur at night. suddenly awakening the patient. They begin with acute abdominal pain in the right upper quadrant that may radiate to the back. between the shoulders. or to the front of the chest; the pain may be so severe that the patient seeks emergency department care. Other features may include recurring fat intolerance. biliary colic. belching. flatulence, indigestion. diaphoresis. nausea. vomiting. chills. low-grade fever. jaundice (if a stone obstructs the common bile duct). and clay-colored stools (with choledocholithiasis).

Clinical features of cholangitis include a rise in eosinophils, jaundice, abdominal pain. high fever. and chills; biliary drrhosis may produce jaundice, related itching, weakness, fatigue. slight weight loss. and abdominal pain. Gallstone ileus produces signs and symptoms of small bowel obstruction - nausea. vomiting, abdominal distention, and absent bowel sounds if the bowel is completely obstructed. Its most telling symptom is intermittent recurrence of colicky pain over several days. Each of these disorders produces its own set of complications.

Diagnosis and testing information

Differential diagnosis is essential in gallbladder and biliary tract disease because gallbladder disease can mimic other diseases (myocardial infarction. angina. pancreatitis. pancreatic head cancer. pneumonia, peptic ulcer, hiatal henda, esophagitis. and gastritis). Serum amylase distinguishes gallbladder disease from pancreatitis. With suspected heart disease. serial cardiac enzyme tests and electrocardiogram should precede gallbladder and upper GI diagnostic tests. Tests used to diagnose gallbladder and biliary tract disease include:

• Ultrasound reflects stones in the gallbladder with 96% accuracy. It's also considered the primary tool for diagnosing cholelithiasis.
• Percutaneous trashepatic cholangiography. done under fluoroscopic control. distinguishes between gallbladder or bile duct disease and cancer of the pancreatic head in patients with jaundice.
• Endoscopic retrograde cholangiopancreatography (ERCP) visualizes the biliary tree after insertion of an endoscope down the esophagus into the duodenum, cannulation of the common bile and pancreatic ducts, and injection of contrast medium.
• HIDA scan of the gallbladder detects obstruction of the cystic duct.
• Computed tomography scan, although not used routinely, helps distinguish between obstructive and non obstructive jaundice.
• Flat plate of the abdomen identifies calcified, but not cholesterol. stones with 15% accuracy.
• Oral cholecystography, which is rarely used, shows stones in the gallbladder and biliary duct obstruction.

Elevated icteric index, total bilirubin, urine bilirubin, and alkaline phosphatase support the diagnosis. White blood cell count is slightly elevated during a cholecystitis attack.

Cholelithiasis treatment

Surgery, usually elective, is the treatment of choice for gallbladder and biliary tract diseases and may include open or laparoscopic cholecystectomy, cholecystectomy with operative cholangiography and, possibly, exploration of the common bile duct. Other treatments include a low-fat diet to prevent attacks and vitamin K for itching, jaundice, and bleeding tendendes due to vitamin K deficiency. Treatment during an acute attack may include insertion of a nasogastric tube and an I.V.line and, possibly, antibiotic and analgesic administration.

A non surgical treatment for choledocholithiasis involves placement of a catheter through the percutaneous transhepatic cholangiographic route. Guided by fluoroscopy, the catheter is directed toward the stone. A basket is threaded through the catheter,opened, twirled to entrap the stone, closed, and withdrawn. This procedure can be performed endoscopically.

Ursodiol (Actigall), which dissolves radiolucent stones, provides an alternative for patients who are poor surgical risks or who refuse surgery. however, use of urdodiol is limited by the need for prolonged treatment, the high incidence of adverse effects, and the frequency of stone formation after the treatment ends.

Extra corporeal shock wave lithotrillsy (ESWL) has also been adapted for the treatment of gallstones. ESWL Is a non surgical procedure used to ('rush stones inside the gallbladder. A lithotripsy machine focuses sound waves against the gallstones to break Them into smaller pieces that can pass out of the gallbladder through the cystic duct and common bile duct into
the small intestine.

................................................................................................................................

SPECIAL NEEDS

Lithotripsy is contraindicated in pregnant women and those who have a pacemaker or serious heart problems.

................................................................................................................................

Special considerations or prevention

Patient care for gallbladder and biliary tract diseases focuses on supportive care and close postoperative observation:

• Before surgery, teach the patient to deep-breathe, cough, expectorate, and perform leg exercises that are necessary after surgery. Also teach splinting, repositioning, and ambulation techniques. Explain the procedures that will be performed before, during, and after surgery to help ease the patient's anxiety and help ensure cooperation.
• After surgery, monitor vital signs for signs of bleeding, infection, or at electasis.
• Evaluate the indsion site for bleeding. Serosanguineous drainage is common during the first 24 to 48 hours if the patient has a wound drain. If, after a choledochostomy, a T-tube drain is placed in the duct and attached to a drainage bag, make sure that the drainage tube has no kinks. Also check that the connecting tubing from the T tube is well secured to the patient to prevent dislodgment.
• Measure and record T-tube drainage daily. (200 to 300 ml is normal.)
• Teach patients who will be discharged with a T tube how to perform dressing changes and routine skin care.
• Monitor intake and output. Allow the patient nothing by mouth for 24 to 48 hours or until bowel sounds return and nausea and vomiting cease. (Postoperative nausea may indicate a full bladder.)
• If the patient doesn't void within 8 hours (or if the amount voided is inadequate based on I.V. fluid intake), percuss over the symphysis pubis for bladder distention (especially in patients receiving anticholinergics). Patients who have had a laparoscopic cholecystectomy may be discharged the same day or within 24 hours after surgery. These patients should have minimal pain, be able to tolerate a regular diet within 24 hours after surgery, and be able to return to normal activity within a few days to 1 week.
• Encourage deep-breathing and leg exercises every hour. The patient should ambulate after surgery. Provide antiembolism stockings to support leg muscles and promote venous blood flow, thus preventing stasis and clot formation.
• Evaluate the location, duration, and character of any pain. Administer adequate medication to relieve pain, especially before such activities as deep breathing and ambulation, which increase pain.
• At discharge, advise the patient against heavy lifting or straining for 6 weeks. Urge her to walk daily. Tell her that food restrictions are Unnecessary unless she has an intolerance to a specific food or some underlying condition (such as diabetes, atherosclerosis, or obesity) that requires such restriction.
• Instruct the patient to notify the surgeon if she has pain for more than 24 hours, notices jaundice, anorexia, nausea or vomiting, fever, or tenderness in the abdominal area because these may indicate a biliary tract injury from cholecystectomy that requires immediate attention.